Basic Information
| Provider Information | |||||||||
| NPI: | 1801224506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA SURGICAL PROFESSIONAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JOHNSON FY RD NE | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4380 GEORGETOWN SQ | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702208400 | ||||||||
| FaxNumber: | 7702349979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2013 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP-ADMIN, CCO | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.