Healthcare Provider Details

I. General information

NPI: 1083892111
Provider Name (Legal Business Name): JACOB NATHAN BLATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HOSPITAL SOUTH DR SUITE 409
AUSTELL GA
30106-6810
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-528-9926
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number057935
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number057935
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: