Provider Demographics
NPI:1174416622
Name:PROGRESSIVE MEDICAL CENTER OF AMERICA LTD
Entity type:Organization
Organization Name:PROGRESSIVE MEDICAL CENTER OF AMERICA LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-676-6000
Mailing Address - Street 1:4646 N SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6308
Mailing Address - Country:US
Mailing Address - Phone:770-676-6000
Mailing Address - Fax:844-313-6296
Practice Address - Street 1:4646 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6308
Practice Address - Country:US
Practice Address - Phone:770-676-6000
Practice Address - Fax:844-313-6296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-02
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty