Healthcare Provider Details

I. General information

NPI: 1588725360
Provider Name (Legal Business Name): MICHAEL CHARLES MIELLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 TULLIE CIR NE
ATLANTA GA
30329-2304
US

IV. Provider business mailing address

1645 TULLIE CIR NE
ATLANTA GA
30329-2304
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-7141
  • Fax:
Mailing address:
  • Phone: 404-785-7141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number024605
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: