Provider Demographics
NPI:1356542997
Name:INTERNAL MEDICINE EDUCATION AND RESEARCH FOUNDATION
Entity type:Organization
Organization Name:INTERNAL MEDICINE EDUCATION AND RESEARCH FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:NICOLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-221-4836
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-0311
Mailing Address - Country:US
Mailing Address - Phone:706-221-4836
Mailing Address - Fax:706-221-4978
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1454
Practice Address - Fax:706-221-4978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17941207RC0200X
NY131631207RC0200X
GA34676207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP616Medicare PIN