1891835021 NPI number — PHILLIP L. POTTER, MD, FACOG, PC

Table of content: (NPI 1891835021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891835021 NPI number — PHILLIP L. POTTER, MD, FACOG, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIP L. POTTER, MD, FACOG, PC
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:
PHILLIP L. POTTER, MD
Provider Other Organization Name Type Code:
5
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:
1891835021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1938 PEACHTREE RD NW
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-352-5119
Provider Business Mailing Address Fax Number:
404-352-5330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 HOSPITAL SOUTH DR
Provider Second Line Business Practice Location Address:
SUITE 504
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-6810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-819-8211
Provider Business Practice Location Address Fax Number:
770-819-9616
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
404-352-5119

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  034220 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00463163B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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