Healthcare Provider Details

I. General information

NPI: 1568661510
Provider Name (Legal Business Name): EMORY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365B CLIFTON RD NE
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

PO BOX 116294
ATLANTA GA
30368-6294
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4500
  • Fax: 404-778-5879
Mailing address:
  • Phone: 404-778-4500
  • Fax: 404-778-5879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD I BRUNN
Title or Position: COO
Credential:
Phone: 404-778-4871