Healthcare Provider Details

I. General information

NPI: 1891835021
Provider Name (Legal Business Name): PHILLIP L. POTTER, MD, FACOG, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HOSPITAL SOUTH DR SUITE 504
AUSTELL GA
30106-6810
US

IV. Provider business mailing address

1938 PEACHTREE RD NW SUITE 303
ATLANTA GA
30309-1267
US

V. Phone/Fax

Practice location:
  • Phone: 770-819-8211
  • Fax: 770-819-9616
Mailing address:
  • Phone: 404-352-5119
  • Fax: 404-352-5330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number034220
License Number StateGA

VIII. Authorized Official

Name: DR. PHILLIP POTTER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 404-352-5119