1578566527 NPI number — STANLEY H DYSART M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	DYSART
Provider First Name	:	STANLEY
Provider Middle Name	:	H
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

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Provider Other First Name	:
Provider Other Middle Name	:
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NPI Number	:	1578566527
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	08/07/2007
NPI Deactivation Reason Code	:
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Provider First Line Business Mailing Address	:	300 TOWER RD NE
Provider Second Line Business Mailing Address	:	STE 200
Provider Business Mailing Address City Name	:	MARIETTA
Provider Business Mailing Address State Name	:	GA
Provider Business Mailing Address Postal Code	:	300609403
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	7704275717
Provider Business Mailing Address Fax Number	:	7704296503

Provider First Line Business Practice Location Address	:	300 TOWER RD NE
Provider Second Line Business Practice Location Address	:	STE 200
Provider Business Practice Location Address City Name	:	MARIETTA
Provider Business Practice Location Address State Name	:	GA
Provider Business Practice Location Address Postal Code	:	300609403
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	7704275717
Provider Business Practice Location Address Fax Number	:	7704296503
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
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• Taxonomy code: 207X00000X , with the licence number:  031591 , registered in the state of GA .

• Identifier: 20BBCZL , issued by the state of ( GA ) . This identifiers is of the category "".
• Identifier: E80424 , issued by the state of ( GA ) . This identifiers is of the category "".