Healthcare Provider Details

I. General information

NPI: 1982804993
Provider Name (Legal Business Name): FULTON DEKALB HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3050
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-6695
  • Fax: 404-616-3297
Mailing address:
  • Phone: 404-616-6695
  • Fax: 404-616-3297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number060069
License Number StateGA

VIII. Authorized Official

Name: MR. DAVID C MAKKERS SR.
Title or Position: DIRECTOR OF MANAGED CARE
Credential:
Phone: 404-616-6695