1174274013 NPI number — METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC

Table of content: (NPI 1174274013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174274013 NPI number — METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC
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:
1174274013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1179 STATE ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30318-5331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-367-2187
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 SHILOH RD NW STE 660
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144-7158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-913-2891
Provider Business Practice Location Address Fax Number:
770-648-2908
Provider Enumeration Date:
01/12/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
SHENELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-913-2891

Provider Taxonomy Codes

  • Taxonomy code: 2088F0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com