Healthcare Provider Details

I. General information

NPI: 1427082494
Provider Name (Legal Business Name): LEWIS ROSS WHATLEY III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N MAIN ST
CEDARTOWN GA
30125-2644
US

IV. Provider business mailing address

80 CARTER RD SW
CARTERSVILLE GA
30120-7446
US

V. Phone/Fax

Practice location:
  • Phone: 770-748-2500
  • Fax:
Mailing address:
  • Phone: 770-386-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number022490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: