Healthcare Provider Details

I. General information

NPI: 1689714784
Provider Name (Legal Business Name): MIDTOWN SURGICAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLLIER RD NW SUITE 4025
ATLANTA GA
30309-1796
US

IV. Provider business mailing address

PO BOX 79105
ATLANTA GA
30357-7105
US

V. Phone/Fax

Practice location:
  • Phone: 404-872-8799
  • Fax: 404-874-3544
Mailing address:
  • Phone: 404-872-8799
  • Fax: 404-874-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN147341
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN150639
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN107268
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN173288
License Number StateGA

VIII. Authorized Official

Name: DUANE PRICKETT
Title or Position: CEO
Credential:
Phone: 404-872-8799