Basic Information
| Provider Information | |||||||||
| NPI: | 1477547784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | CONSTANIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 SANDY PLAINS ROAD | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300666340 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 S 8TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302244260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702296072 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 032140 | GA | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00569698B | 05 | GA | MEDICAID | 360003154/CM0845 | 01 | GA | RAILROAD MEDICARE | OTHER |