Basic Information
| Provider Information | |||||||||
| NPI: | 1548395957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAILE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | HARLEY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1285 UPPER HEMBREE RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300761143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703438565 | ||||||||
| FaxNumber: | 7703438651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | STE 3600 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703438565 | ||||||||
| FaxNumber: | 7707813559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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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 | 363A00000X | 641 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100001027A | 05 | GA | MEDICAID |