Healthcare Provider Details

I. General information

NPI: 1407062706
Provider Name (Legal Business Name): PEACHTREE COLON AND RECTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE SUITE 540
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

2001 PEACHTREE RD NE SUITE 540
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-2001
  • Fax: 404-352-8418
Mailing address:
  • Phone: 404-351-2001
  • Fax: 404-352-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35712
License Number StateGA

VIII. Authorized Official

Name: DR. JOSEPH J NICHOLS JR.
Title or Position: MEMBER LLC
Credential: M.D.
Phone: 404-351-2001