Basic Information
| Provider Information | |||||||||
| NPI: | 1376624940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT HEALTHCARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102847 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708012500 | ||||||||
| FaxNumber: | 7708032121 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046053368 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 013307 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 313138862A | 05 | GA | MEDICAID |