Healthcare Provider Details

I. General information

NPI: 1033037171
Provider Name (Legal Business Name): ABRAHAM ELLENBOGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1215 GODFREY LN
NISKAYUNA NY
12309-1241
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-2000
  • Fax:
Mailing address:
  • Phone: 518-925-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: