Healthcare Provider Details

I. General information

NPI: 1578622429
Provider Name (Legal Business Name): GREG SEDOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 07/08/2007
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

1117 CAMDEN HUNT CT
LAWRENCEVILLE GA
30043-6324
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-5519
  • Fax: 404-616-9213
Mailing address:
  • Phone: 404-616-5519
  • Fax: 404-616-9213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number000422
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: