Healthcare Provider Details

I. General information

NPI: 1710858592
Provider Name (Legal Business Name): HERITAGE MEDICAL MANAGEMENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 CLEVELAND AVE SW
ATLANTA GA
30315-7129
US

IV. Provider business mailing address

777 CLEVELAND AVE SW
ATLANTA GA
30315-7129
US

V. Phone/Fax

Practice location:
  • Phone: 404-755-2291
  • Fax: 732-347-3388
Mailing address:
  • Phone: 678-621-0421
  • Fax: 732-347-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVE O ODEH
Title or Position: CEO
Credential:
Phone: 404-242-9621