Healthcare Provider Details

I. General information

NPI: 1720571474
Provider Name (Legal Business Name): ROMANUS C OBIALOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR
ATLANTA GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-3800
  • Fax:
Mailing address:
  • Phone: 770-843-5870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number160724
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: