Basic Information
| Provider Information | |||||||||
| NPI: | 1831127760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | NANI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCANDLESS | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD NE | ||||||||
| Address2: | NINE PEADMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303501736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3550 PRESTON RIDGE ROAD | ||||||||
| Address2: | KP ALPHANETTA MEDICAL CENTER | ||||||||
| City: | ALPHANETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706633303 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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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 | 2080A0000X | 041434 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000781448W | 05 | GA | MEDICAID |