Basic Information
| Provider Information | |||||||||
| NPI: | 1265402317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | THEOLYN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 HOSPITAL BLVD STE 420 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042497327 | ||||||||
| FaxNumber: | 7704210228 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 HOSPITAL BLVD STE 420 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042497327 | ||||||||
| FaxNumber: | 7704210228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 45827 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | ME110622 | FL | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 52769 | CO | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 80819 | GA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 003983700 | 05 | MN | MEDICAID | P00042740 | 01 | MN | RAILROAD MEDICARE | OTHER | ENROLLED | 05 | IA | MEDICAID | 35294500 | 05 | WI | MEDICAID |