1124571104 NPI number — UROLOGY SURGERY CENTER JOHNS CREEK LLC

Table of content: (NPI 1124571104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124571104 NPI number — UROLOGY SURGERY CENTER JOHNS CREEK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGY SURGERY CENTER JOHNS CREEK LLC
Provider Last Name:
Provider First Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1124571104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1551 JANMAR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SNELLVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30078-5606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-344-8900
Provider Business Mailing Address Fax Number:
678-666-5201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10730 MEDLOCK BRIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-344-8900
Provider Business Practice Location Address Fax Number:
678-666-5201
Provider Enumeration Date:
07/26/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
JITESH
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-344-8900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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