Provider Demographics
NPI:1437194156
Name:PEACHTREE IMMEDIATE CARE FP, LLC
Entity type:Organization
Organization Name:PEACHTREE IMMEDIATE CARE FP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, BILLING OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-679-6471
Mailing Address - Street 1:590 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1504
Mailing Address - Country:US
Mailing Address - Phone:678-688-9685
Mailing Address - Fax:770-626-3791
Practice Address - Street 1:3827 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2630
Practice Address - Country:US
Practice Address - Phone:770-222-8900
Practice Address - Fax:770-222-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137060AMedicaid
GA003137060AMedicaid