Healthcare Provider Details

I. General information

NPI: 1760626279
Provider Name (Legal Business Name): ALPHONSUS MADUWUBA AGBAERE MT(ASCP)CLS(NCA)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

2222 COLUMBIA DR
DECATUR GA
30032-7206
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 404-286-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number163311
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number163311
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: