Healthcare Provider Details

I. General information

NPI: 1114767043
Provider Name (Legal Business Name): ADAM THOMAS BULLOCK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N DECATUR RD
DECATUR GA
30033-5918
US

IV. Provider business mailing address

927 KATIE KERR DR
DECATUR GA
30030-4151
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-1000
  • Fax:
Mailing address:
  • Phone: 704-918-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN299635
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN299635
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License NumberRN299635
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: