Healthcare Provider Details

I. General information

NPI: 1619591450
Provider Name (Legal Business Name): BRIAN PALLONE AT., C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2020
Last Update Date: 06/07/2020
Certification Date: 06/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N DECATUR RD STE 200
DECATUR GA
30033-5936
US

IV. Provider business mailing address

2775 CAROLINA DR
BETHLEHEM GA
30620-4642
US

V. Phone/Fax

Practice location:
  • Phone: 404-296-5005
  • Fax:
Mailing address:
  • Phone: 770-337-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: