Healthcare Provider Details

I. General information

NPI: 1396732657
Provider Name (Legal Business Name): ROY LAMAR TALLEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: R L TALLEY JR. MD

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE SUITE 100
CONYERS GA
30012
US

IV. Provider business mailing address

1301 SIGMAN RD NE STE 100
CONYERS GA
30012-3812
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9360
  • Fax: 770-760-9303
Mailing address:
  • Phone: 770-760-9360
  • Fax: 770-760-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number29957
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number29957
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: