Provider Demographics
NPI:1730194457
Name:TMC INTERNAL MEDICINE ASSOCIATES VILLA RICA
Entity type:Organization
Organization Name:TMC INTERNAL MEDICINE ASSOCIATES VILLA RICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREILING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-8038
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:770-836-9261
Practice Address - Street 1:690 DALLAS HWY
Practice Address - Street 2:SUITE 303
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1209
Practice Address - Country:US
Practice Address - Phone:770-456-3790
Practice Address - Fax:770-456-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH5396OtherMEDICARE ID
GACH5396OtherMEDICARE ID