Healthcare Provider Details

I. General information

NPI: 1083617872
Provider Name (Legal Business Name): THOMAS S BACKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date: 03/30/2006
Reactivation Date: 06/21/2006

III. Provider practice location address

3905 BROOKSIDE PKWY STE 202
ALPHARETTA GA
30022-4425
US

IV. Provider business mailing address

3905 BROOKSIDE PKWY STE 202
ALPHARETTA GA
30022-4425
US

V. Phone/Fax

Practice location:
  • Phone: 770-751-9131
  • Fax: 770-751-9132
Mailing address:
  • Phone: 770-751-9131
  • Fax: 770-751-9132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number030711
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number030711
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: