Basic Information
| Provider Information | |||||||||
| NPI: | 1952771230 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGIA UROLOGY, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GA UROLOGY ASC ROSWELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11835 ALPHARETTA HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707724427 | ||||||||
| FaxNumber: | 7707724428 | ||||||||
| Practice Location | |||||||||
| Address1: | 11835 ALPHARETTA HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704757550 | ||||||||
| FaxNumber: | 7703439080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HABER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6782844049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA UROLOGY, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.