Healthcare Provider Details

I. General information

NPI: 1790951325
Provider Name (Legal Business Name): ROSS M FASANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2008
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303
US

IV. Provider business mailing address

1405 CLIFTON RD NE DEPT OF
ATLANTA GA
30322-1062
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1300
  • Fax:
Mailing address:
  • Phone: 404-785-5532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD036088
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number072580
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number072580
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: