Healthcare Provider Details

I. General information

NPI: 1295290450
Provider Name (Legal Business Name): GEORGIA PALLIATIVE CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2849 PACES FERRY RD SE STE 380
ATLANTA GA
30339-3769
US

IV. Provider business mailing address

206 N 2100 W STE 202
SALT LAKE CITY UT
84116-4741
US

V. Phone/Fax

Practice location:
  • Phone: 470-737-0300
  • Fax: 801-883-8044
Mailing address:
  • Phone: 801-924-8571
  • Fax: 801-883-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK L PHILLIPS
Title or Position: NATIONAL DIRECTOR OF PHYSICIAN SER.
Credential:
Phone: 801-924-4992