Healthcare Provider Details

I. General information

NPI: 1750663118
Provider Name (Legal Business Name): SOUTHEASTERN GYNECOLOGIC ONCOLOGY AT SAINT JOSEPH'S, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD NE SUITE 900
ATLANTA GA
30342-1609
US

IV. Provider business mailing address

980 JOHNSON FERRY ROAD, SUITE 900
ATLANTA GA
30342-1609
US

V. Phone/Fax

Practice location:
  • Phone: 678-420-4100
  • Fax: 678-420-4111
Mailing address:
  • Phone: 678-420-4100
  • Fax: 678-420-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD D REED
Title or Position: PRESIDENT
Credential:
Phone: 678-843-6409