MEDICARE: ATLANTA SURGICAL ASSISTANCE

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	363LW0102X	Women's Health Nurse Practitioner	RN130308NP	GA

General Provider Information

NPI Number	:	1336458280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTA SURGICAL ASSISTANCE

Provider Business Mailing Address
First Line	:	3466 MARK HALL DR NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-5342
Country	:	US
Telephone Number	:	770-565-1276
Fax Number	:	888-329-6432

Provider Business Practice Location Address
First Line	:	105 COLLIER RD NW STE 1080
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-1753
Country	:	US
Telephone Number	:	404-352-2850
Fax Number	:	888-329-6432

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JANET A DORTCH
Credential	:	NP
Telephone Number	:	404-797-2497

Provider Enumeration Date	:	09/27/2010
Last Update Date	:	09/27/2010

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