Basic Information
| Provider Information | |||||||||
| NPI: | 1407116056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMNESTIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 DALLAS HWY SW STE 202 | ||||||||
| Address2: | BOX 160 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300647505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 AUSTELL RD | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | SANUSI | ||||||||
| AuthorizedOfficialFirstName: | HANI | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7066608505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 036450 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 036450 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.