Basic Information
| Provider Information | |||||||||
| NPI: | 1689343550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIGNATURE WOMEN'S HEALTHCARE OF GEORGIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043038035 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 HILLANDALE DR STE 245 | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300586801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703239300 | ||||||||
| FaxNumber: | 6783952023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2021 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | ZANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4043038035 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATLANTA WOMEN'S HEALTH GROUP, P.C. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 300034164A | 05 | GA | MEDICAID |