1811084759 NPI number — ATLANTA METRO UROLOGY CLINICS PC

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 1811084759 NPI number — ATLANTA METRO UROLOGY CLINICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA METRO UROLOGY CLINICS 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:
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:
1811084759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 HIGHWAY 54 W
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-4549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-716-9656
Provider Business Mailing Address Fax Number:
770-716-1609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 HIGHWAY 54 W
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-4549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-716-9656
Provider Business Practice Location Address Fax Number:
770-716-1609
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DURALDE
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-716-9656

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: CN9719 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 55002145A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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