Healthcare Provider Details

I. General information

NPI: 1285632190
Provider Name (Legal Business Name): BRETT L SANDIFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 MEDICAL PARK DR
AUSTELL GA
30106-1110
US

IV. Provider business mailing address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-6041
  • Fax: 770-739-5411
Mailing address:
  • Phone: 770-948-5409
  • Fax: 770-948-7994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number051381
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number051381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: