Basic Information
| Provider Information | |||||||||
| NPI: | 1952335424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGI | ||||||||
| FirstName: | EMIL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 BRECKINRIDGE BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300967611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782260082 | ||||||||
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| Practice Location | |||||||||
| Address1: | DODGE COUNTY HOSPITAL | ||||||||
| Address2: | 715 GRIFFIN AVE SW | ||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784484042 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 019048 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000276944B | 05 | GA | MEDICAID |