Blackpool LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

058633 Issued in GA

Legal business name

BLACKPOOL LLC

Doing business as

Georgia Medical Clinic

Practice address

4415 Front Nine Dr Ste 600
Cumming, GA 30041-6239

Phone

(770) 744-7688

Fax

(770) 406-1058

NPI assigned

Apr 1, 2013

Last updated

Feb 14, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Venkatappa Rangaraj, MDNPI 1588690879

Title

Owner

Phone

(513) 218-3468

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Georgia Medical Clinic Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Venkatappa Rangaraj, M.D.

  • Internal Medicine Physician
  • Cumming, GA
  • NPI 1588690879
  Medicare reassignment Care Compare group NPD Authorized official
• Gladys B Johnson

  • Family Nurse Practitioner
  • Stone Mountain, GA
  • NPI 1407458102
  Medicare reassignment Care Compare group NPD
• Angella Samuels, DNP

  • Nurse Practitioner
  • Snellville, GA
  • NPI 1043406069
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1364774400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1676332800000",
    "number": "1124361811",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4415 FRONT NINE DR STE 600",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300416239",
            "telephone_number": "770-744-7688",
            "fax_number": "770-406-1058"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4415 FRONT NINE DR STE 600",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300416239",
            "telephone_number": "770-744-7688",
            "fax_number": "770-406-1058"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACKPOOL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-01",
        "last_updated": "2023-02-14",
        "certification_date": "2023-02-14",
        "status": "A",
        "authorized_official_last_name": "RANGARAJ",
        "authorized_official_first_name": "VENKATAPPA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "513-218-3468",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": "058633",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003132617A",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Blueehs",
            "affiliation": "N",
            "endpointDescription": "EMR",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "EMR",
            "address_1": "4415 Front Nine Dr Ste 600",
            "city": "Cumming",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300416239",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Georgia Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Georgia Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Internal Medicine Physician in Cumming, GA
• Providers in Cumming, GA by specialty
• Internal Medicine Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.