Provider Demographics
NPI:1033090451
Name:MIXED MEDICAL MEDIA
Entity type:Organization
Organization Name:MIXED MEDICAL MEDIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:678-902-9495
Mailing Address - Street 1:1106 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6381
Mailing Address - Country:US
Mailing Address - Phone:678-902-9495
Mailing Address - Fax:678-815-1548
Practice Address - Street 1:1106 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6381
Practice Address - Country:US
Practice Address - Phone:678-902-9495
Practice Address - Fax:678-815-1548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIXED MEDICAL MEDIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151504EMedicaid