Healthcare Provider Details

I. General information

NPI: 1790742526
Provider Name (Legal Business Name): LAWRENCE LEO GOLUSINSKI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 PEACHTREE ST NE STE 12
ATLANTA GA
30309-6857
US

IV. Provider business mailing address

285 BOULEVARD NE STE 640
ATLANTA GA
30312-4205
US

V. Phone/Fax

Practice location:
  • Phone: 404-253-3660
  • Fax:
Mailing address:
  • Phone: 404-577-7800
  • Fax: 404-577-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number038777
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number038777
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: