Healthcare Provider Details

I. General information

NPI: 1962497941
Provider Name (Legal Business Name): RICHARD MARK SCHLOSSBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 7TH ST
AUBURN GA
30011-3202
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-822-5555
  • Fax: 770-822-6117
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number044330
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: