# ROYAL BLUE MEDICAL CENTER GA. INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Royal Blue Medical Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1942845417
- **Authorized official:** MR. OMAR ELLISON (OWNER)
- **Authorized official phone:** (704) 277-1750

## Contact information

- **Practice address:** 555 OLD NORCROSS RD STE 100, LAWRENCEVILLE, GA 30046-8703
- **Practice address phone:** (704) 277-1750
- **Mailing address:** 2023 CONNONADE DR, WAXHAW, NC 28173-0109
- **Mailing address phone:** (704) 277-1750

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2081S0010X | Sports Medicine (Physical Medicine & Rehabilitation) Physician | — | NULL | — |
| 2081S0010X | Sports Medicine (Physical Medicine & Rehabilitation) Physician | — | — | — |
| 2083S0010X | Sports Medicine (Preventive Medicine) Physician | — | NULL | — |
| 2083S0010X | Sports Medicine (Preventive Medicine) Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |
| 261QP3300X | Pain Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 11/08/2019
- **Last updated:** 09/08/2020