Healthcare Provider Details

I. General information

NPI: 1699215541
Provider Name (Legal Business Name): MARY M FELDMAN MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2017
Last Update Date: 02/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL PL STE 110
CARROLLTON GA
30117-3874
US

IV. Provider business mailing address

100 PROFESSIONAL PL STE 110
CARROLLTON GA
30117-3874
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-0818
  • Fax: 770-834-5098
Mailing address:
  • Phone: 770-834-0818
  • Fax: 770-834-5098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number69043
License Number StateGA

VIII. Authorized Official

Name: DR. MARY M FELDMAN
Title or Position: OWNER
Credential: MD
Phone: 504-231-5544