1548541030 NPI number — GEORGIA UROLOGY PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548541030 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:
1548541030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2015
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:
4450 CALIBRE XING NW
Provider Second Line Business Practice Location Address:
STE 1200
Provider Business Practice Location Address City Name:
ACWORTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30101-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-607-1893
Provider Business Practice Location Address Fax Number:
770-607-2930
Provider Enumeration Date:
08/29/2011

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: 11D2033897 . This is a "CLIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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