Basic Information
| Provider Information | |||||||||
| NPI: | 1598742405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEEMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5775 GLENRIDGE DR NE | ||||||||
| Address2: | BUILDING B, SUITE 145 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046595909 | ||||||||
| FaxNumber: | 7703999449 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 N DECATUR RD | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300336131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046595909 | ||||||||
| FaxNumber: | 7703999449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208100000X | 028767 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 00400793A | 05 | GA | MEDICAID |