Healthcare Provider Details

I. General information

NPI: 1134359599
Provider Name (Legal Business Name): IMAD ABOSSALLUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

5605 GLENRIDGE DR STE 325
ATLANTA GA
30342-1301
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6323
  • Fax: 404-303-3747
Mailing address:
  • Phone: 404-252-4709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME121864
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009010810
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301102046
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME121864
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number88214
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: