Basic Information
| Provider Information | |||||||||
| NPI: | 1609091891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA UROLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782844040 | ||||||||
| FaxNumber: | 6782844076 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 NORTHSIDE CHEROKEE BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301158015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707207246 | ||||||||
| FaxNumber: | 7707204620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2007 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | HABER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6782844049 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA UROLOGY PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 11D0943320 | 01 | GA | CLIA | OTHER |