Basic Information
| Provider Information | |||||||||
| NPI: | 1346293164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REA | ||||||||
| FirstName: | ALFONSO | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 51719 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 473403602B | 05 | GA | MEDICAID | 000958548J | 05 | GA | MEDICAID | 000958548M | 05 | GA | MEDICAID | 000958548K | 05 | GA | MEDICAID |