Healthcare Provider Details

I. General information

NPI: 1780853200
Provider Name (Legal Business Name): ATLANTA MINIMALLY INVASIVE GYNECOLOGIC SURGERY CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COLLIER RD NW SUITE 1010
ATLANTA GA
30309-1710
US

IV. Provider business mailing address

105 COLLIER RD NW SUITE 1010
ATLANTA GA
30309-1710
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-4885
  • Fax: 404-355-2210
Mailing address:
  • Phone: 404-355-4885
  • Fax: 404-355-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number045895
License Number StateGA

VIII. Authorized Official

Name: FREEDOM MITCHELL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 404-355-4885