Basic Information
| Provider Information | |||||||||
| NPI: | 1013958511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE UROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 PIEDMONT RD NE | ||||||||
| Address2: | SUITE 7-601 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048425400 | ||||||||
| FaxNumber: | 4048481225 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 DOWNWOOD CIR NW | ||||||||
| Address2: | SUITE 680 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303271610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043557272 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | MAXWELL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4043557272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 028233 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.