Healthcare Provider Details

I. General information

NPI: 1780739318
Provider Name (Legal Business Name): FAIRBURN SOUTHPARK MEDICAL AND SURGICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SENOIA RD
FAIRBURN GA
30213-1536
US

IV. Provider business mailing address

204 SENOIA RD
FAIRBURN GA
30213-1536
US

V. Phone/Fax

Practice location:
  • Phone: 770-964-9759
  • Fax: 770-964-7001
Mailing address:
  • Phone: 770-964-9759
  • Fax: 770-964-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RENATO CHAVES SOUZA
Title or Position: PRESIDENT TREASURER
Credential: MD
Phone: 770-964-9759