Healthcare Provider Details

I. General information

NPI: 1669758991
Provider Name (Legal Business Name): PHILIP JAFFE AA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
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
30303-3031
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 Number006207
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: