Basic Information
| Provider Information | |||||||||
| NPI: | 1376163451 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA UROLOGY PIEDMONT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
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| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 SIGMAN RD NE STE 250A | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707609900 | ||||||||
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| ProviderEnumerationDate: | 04/20/2020 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | LACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6782844040 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA UROLOGY, PA | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.