Healthcare Provider Details

I. General information

NPI: 1447861950
Provider Name (Legal Business Name): PHYNOVA MSO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 PEACHTREE ST NW STE 380
ATLANTA GA
30309-2498
US

IV. Provider business mailing address

PO BOX 54157
ATLANTA GA
30308-0157
US

V. Phone/Fax

Practice location:
  • Phone: 770-270-5229
  • Fax: 770-270-9323
Mailing address:
  • Phone: 770-270-5229
  • Fax: 770-270-9323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: LAVERNE W POINDEXTER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 770-270-5229