Provider Demographics
NPI:1528097318
Name:TRI COUNTY INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:TRI COUNTY INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:COKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-945-1990
Mailing Address - Street 1:4720 NELSON BROGDON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3480
Mailing Address - Country:US
Mailing Address - Phone:770-945-1990
Mailing Address - Fax:678-745-4139
Practice Address - Street 1:4720 NELSON BROGDON BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-3480
Practice Address - Country:US
Practice Address - Phone:770-945-1990
Practice Address - Fax:678-745-4139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4338490001Medicare NSC
GAGRP4153Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER