Basic Information
| Provider Information | |||||||||
| NPI: | 1639499627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA UROLOGY, PA | ||||||||
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| OtherOrganizationName: | GEORGIA UROLOGY ASC MARIETTA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 790 CHURCH ST NE | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300607282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704299100 | ||||||||
| FaxNumber: | 7704291391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | HABER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6782844049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA UROLOGY, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.