Basic Information
| Provider Information | |||||||||
| NPI: | 1689801532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TALIAFERRO | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY ROAD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 PRINCE AVE | ||||||||
| Address2: | BUILDING #3 | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306065908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065484272 | ||||||||
| FaxNumber: | 7065489181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 068956 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 003134156A | 05 | GA | MEDICAID |