Basic Information
| Provider Information | |||||||||
| NPI: | 1467410977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKELSON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MICKELSON | ||||||||
| OtherFirstName: | SAMUEL | ||||||||
| OtherMiddleName: | ALAN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 960 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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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 | 207Y00000X | 041173 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0012X | 041173 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine |
No ID Information.