Healthcare Provider Details

I. General information

NPI: 1396873527
Provider Name (Legal Business Name): GEORGIA INSTITUTE OF TECHNOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 FERST DRIVE, NW
ATLANTA GA
30332-0470
US

IV. Provider business mailing address

740 FERST DRIVE, NW
ATLANTA GA
30332-0470
US

V. Phone/Fax

Practice location:
  • Phone: 404-894-1430
  • Fax: 404-894-4142
Mailing address:
  • Phone: 404-894-7294
  • Fax: 404-894-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberPHRE005743
License Number StateGA

VIII. Authorized Official

Name: GREGORY MOORE
Title or Position: SENIOR DIRECTOR
Credential: M.D.
Phone: 404-895-3256