Healthcare Provider Details

I. General information

NPI: 1659516367
Provider Name (Legal Business Name): DANIEL MICHAEL FECKOURY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 DIXIE ST STE 350
CARROLLTON GA
30117-3860
US

IV. Provider business mailing address

2727 PACES FERRY RD SE STE 1-1100
ATLANTA GA
30339-6151
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-5831
  • Fax: 770-812-5832
Mailing address:
  • Phone: 770-486-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number080953
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: