Basic Information
| Provider Information | |||||||||
| NPI: | 1033618806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMEN'S HEALTHCARE ASSOCIATES OF ATHENS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063690019 | ||||||||
| FaxNumber: | 7063691989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | ZANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4043031224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATLANTA WOMEN'S HEALTH GROUP, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GRP3569 | 01 | GA | OPTOUT | OTHER | 300034164A | 05 | GA | MEDICAID |