1851517072 NPI number — GEORGIA UROLOGY PA

Table of content: (NPI 1851517072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851517072 NPI number — GEORGIA UROLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA UROLOGY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851517072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 BRANNAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-4310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-284-4040
Provider Business Mailing Address Fax Number:
678-284-4076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4298 ATLANTA RD. SE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-429-9100
Provider Business Practice Location Address Fax Number:
770-429-1391
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HABER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
678-284-4049

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11D0902145 . This is a "CLIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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