Basic Information
| Provider Information | |||||||||
| NPI: | 1962558460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWTON ROCKDALE SURGICAL SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1372 WELLBROOK CIR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709224024 | ||||||||
| FaxNumber: | 7709228143 | ||||||||
| Practice Location | |||||||||
| Address1: | 1372 WELLBROOK CIR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709224024 | ||||||||
| FaxNumber: | 7709228143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ISSHAK | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7709224024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.