Healthcare Provider Details

I. General information

NPI: 1548218605
Provider Name (Legal Business Name): BRUCE H. WAINER M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 CLIFTON RD NE ROOM 208
ATLANTA GA
30329-4021
US

IV. Provider business mailing address

1841 CLIFTON RD NE ROOM 208
ATLANTA GA
30329-4021
US

V. Phone/Fax

Practice location:
  • Phone: 404-728-4888
  • Fax: 404-728-4917
Mailing address:
  • Phone: 404-728-4888
  • Fax: 404-728-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number041025
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: