MEDICARE: ALTELISHA LANAE TAYLOR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	A178138	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207QS0010X	Sports Medicine (Family Medicine) Physician	11034	GA

General Provider Information

NPI Number	:	1093277899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALTELISHA LANAE TAYLOR MD

Provider Business Mailing Address
First Line	:	455 LEE ST SW FL 2
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 LEE ST SW FL 2
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1408
Country	:	US
Telephone Number	:	404-756-1241
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	06/28/2023

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