Basic Information
| Provider Information | |||||||||
| NPI: | 1538247556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZELLER | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR 202 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708388563 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 PROFESSIONAL PL | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708340170 | ||||||||
| FaxNumber: | 7702141546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 47043 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 581456616 | 01 | GA | TAX ID | OTHER | 333750 | 01 | GA | WELLCARE | OTHER | 52728648001 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000824051A | 01 | GA | PEACH STATE | OTHER | 00824051A | 05 | GA | MEDICAID |