MEDICARE: BODY LOGIC OF ATLANTA

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	207Q00000X	Family Medicine Physician	46540	GA

General Provider Information

NPI Number	:	1740724848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY LOGIC OF ATLANTA

Provider Business Mailing Address
First Line	:	2941 PIEDMONT RD NE
Second Line	:	SUITE C
City	:	ATLANTA
State	:	GA
Zip	:	30305-2784
Country	:	US
Telephone Number	:	404-608-0376
Fax Number	:

Provider Business Practice Location Address
First Line	:	2941 PIEDMONT RD NE
Second Line	:	SUITE C
City	:	ATLANTA
State	:	GA
Zip	:	30305-2784
Country	:	US
Telephone Number	:	404-608-0376
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MRS. ANDREE NECOLE MATTHEWS
Credential	:
Telephone Number	:	678-613-2971

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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