Provider Demographics
NPI:1902167935
Name:DIVINITY INTERNAL MEDICINE & ASSOCIATES INC.
Entity Type:Organization
Organization Name:DIVINITY INTERNAL MEDICINE & ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KYWAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-724-0862
Mailing Address - Street 1:4426 HUGH HOWELL RD STE B160
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4918
Mailing Address - Country:US
Mailing Address - Phone:678-724-0862
Mailing Address - Fax:
Practice Address - Street 1:494 BOULEVARD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-3426
Practice Address - Country:US
Practice Address - Phone:404-607-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA154999305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service