Healthcare Provider Details

I. General information

NPI: 1316146483
Provider Name (Legal Business Name): ATL COLORECTAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLLIER RD NW SUITE 4025
ATLANTA GA
30309-1796
US

IV. Provider business mailing address

2221 PEACHTREE RD NE SUITE D442
ATLANTA GA
30309-1148
US

V. Phone/Fax

Practice location:
  • Phone: 404-574-5820
  • Fax: 404-574-5821
Mailing address:
  • Phone: 404-574-5820
  • Fax: 619-789-6513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number53247
License Number StateGA

VIII. Authorized Official

Name: MONICA HUM
Title or Position: PRES
Credential: M. D.
Phone: 404-574-5820