Healthcare Provider Details

I. General information

NPI: 1972787760
Provider Name (Legal Business Name): GLEN JOSEPH IANNUCCI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OLD MILTON PKWY STE 100
ALPHARETTA GA
30005-2425
US

IV. Provider business mailing address

2835 BRANDYWINE RD SUITE 300
ATLANTA GA
30341-5510
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2593
  • Fax: 770-488-9408
Mailing address:
  • Phone: 404-256-2593
  • Fax: 770-488-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number002845
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number064569
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: