Basic Information
| Provider Information | |||||||||
| NPI: | 1871096305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OB-GYN ASSOCIATES OF MARIETTA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 699 CHURCH ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704228700 | ||||||||
| FaxNumber: | 7704257601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2018 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6788916541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATLANTA WOMEN'S HEALTH GROUP, P.C. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GRP3569 | 01 | GA | OB/GYN | OTHER | 300034164A | 05 | GA | MEDICAID |