Basic Information
| Provider Information | |||||||||
| NPI: | 1629657119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISMAEL | ||||||||
| FirstName: | EMAN | ||||||||
| MiddleName: | Y | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1178 LEYBOURNE CV | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300453572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035644420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707935000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2021 | ||||||||
| LastUpdateDate: | 04/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.