Healthcare Provider Details

I. General information

NPI: 1184205478
Provider Name (Legal Business Name): SAM SECORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FY RD NE
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

57 EXECUTIVE PARK S STE 300
ATLANTA GA
30329-2287
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-8000
  • Fax:
Mailing address:
  • Phone: 404-727-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number11587
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: