Idlewood Medical Clinic Inc

Primary specialty

Adult Medicine PhysicianTaxonomy code 207QA0505X

Legal business name

IDLEWOOD MEDICAL CLINIC INC

Practice address

2157 Idlewood Rd
Ste B
Tucker, GA 30084-4832

Phone

(305) 388-4383

Fax

(305) 388-4380

NPI assigned

Nov 29, 2010

Organization subpart

No

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

Authorized official

Name

Aida Rosa De la Vega

Title

Ceo

Phone

(305) 388-4383

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1290988800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1292544000000",
    "number": "1316249246",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2157 IDLEWOOD RD",
            "address_2": "STE B",
            "city": "TUCKER",
            "state": "GA",
            "postal_code": "300844832",
            "telephone_number": "305-388-4383",
            "fax_number": "305-388-4380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2157 IDLEWOOD RD",
            "address_2": "STE B",
            "city": "TUCKER",
            "state": "GA",
            "postal_code": "300844832",
            "telephone_number": "305-388-4383",
            "fax_number": "305-388-4380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDLEWOOD MEDICAL CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-11-29",
        "last_updated": "2010-12-17",
        "status": "A",
        "authorized_official_last_name": "DE LA VEGA",
        "authorized_official_first_name": "AIDA",
        "authorized_official_middle_name": "ROSA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "305-388-4383"
    },
    "taxonomies": [
        {
            "code": "207QA0505X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Adult Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.