Provider Demographics
NPI:1679347033
Name:DARTMOUTH MEDICAL LLC
Entity type:Organization
Organization Name:DARTMOUTH MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIAN
Authorized Official - Middle Name:LIANG
Authorized Official - Last Name:PANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-610-9339
Mailing Address - Street 1:2959 SHARPSBURG MCCULLUM RD # 103
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2297
Mailing Address - Country:US
Mailing Address - Phone:770-202-1642
Mailing Address - Fax:770-202-1643
Practice Address - Street 1:2959 SHARPSBURG MCCULLUM RD # 103
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2297
Practice Address - Country:US
Practice Address - Phone:617-610-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty