MEDICARE: UNIVERSAL LUNG ASSOCIATES

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	261QM2500X	Medical Specialty Clinic/Center	58391	GA

General Provider Information

NPI Number	:	1770881021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSAL LUNG ASSOCIATES

Provider Business Mailing Address
First Line	:	550 PEACHTREE ST NE
Second Line	:	SUITE 1285
City	:	ATLANTA
State	:	GA
Zip	:	30308-2208
Country	:	US
Telephone Number	:	404-856-3216
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 PEACHTREE ST NE
Second Line	:	SUITE 1285
City	:	ATLANTA
State	:	GA
Zip	:	30308-2208
Country	:	US
Telephone Number	:	404-856-3216
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	DR. OLUFUNSHO OLADIPO BANKOLE
Credential	:	M.D
Telephone Number	:	806-290-0485

Provider Enumeration Date	:	03/10/2011
Last Update Date	:	03/10/2011

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Directions to “UNIVERSAL LUNG ASSOCIATES ” Practice Location

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