MEDICARE: BUCKHEAD SURGICAL ASSOCIATES LLC

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	208600000X	Surgery Physician	41097	GA

General Provider Information

NPI Number	:	1972843084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKHEAD SURGICAL ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	2061 PEACHTREE RD NE
Second Line	:	SUITE 300
City	:	ATLANTA
State	:	GA
Zip	:	30309-1427
Country	:	US
Telephone Number	:	404-350-7955
Fax Number	:	404-350-9115

Provider Business Practice Location Address
First Line	:	2061 PEACHTREE RD NE
Second Line	:	SUITE 300
City	:	ATLANTA
State	:	GA
Zip	:	30309-1427
Country	:	US
Telephone Number	:	404-350-7955
Fax Number	:	404-350-9115

Authorized Official
Title or Position	:	OWNER/M.D.
Name	:	DR. J. DEWAYNE COLQUITT
Credential	:	M.D.
Telephone Number	:	404-350-7955

Provider Enumeration Date	:	02/26/2013
Last Update Date	:	01/14/2014

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