Organization
DONE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CREDENTIALING DEPARTMENT (OFFICE MANAGER/BUSINESS STAFF CONTA)
(415) 671-2165
Entity
Organization
Contact information
Practice address
1201 W PEACHTREE ST NW STE 2300, ATLANTA, GA 30309-3453
(415) 735-5804
Mailing address
1201 W PEACHTREE ST NW STE 2300, ATLANTA, GA 30309-3453
(415) 735-5804
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
94465
MD
GA
Enumeration date
10/17/2023
Last updated
11/08/2023
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