Healthcare Provider Details

I. General information

NPI: 1669971214
Provider Name (Legal Business Name): MOODY SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 11/05/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 DULUTH PARK LN STE 290
DULUTH GA
30096
US

IV. Provider business mailing address

7635 BLANDFORD PL
ATLANTA GA
30350-5603
US

V. Phone/Fax

Practice location:
  • Phone: 706-489-9623
  • Fax:
Mailing address:
  • Phone: 770-676-6873
  • Fax: 770-676-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA MOODY
Title or Position: FOUNDER/OWNER
Credential: MD
Phone: 409-877-8875