Healthcare Provider Details

I. General information

NPI: 1770942856
Provider Name (Legal Business Name): GEORGIA UROLOGY PEDIATRIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE DR STE 200
ATLANTA GA
30328-6141
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-1844
  • Fax: 404-252-5642
Mailing address:
  • Phone: 678-284-4040
  • Fax: 678-284-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK A HABER
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 678-284-4040