Healthcare Provider Details

I. General information

NPI: 1700029402
Provider Name (Legal Business Name): IDI ALLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 YORKTOWN DR STE 211
FAYETTEVILLE GA
30214-1578
US

IV. Provider business mailing address

101 YORKTOWN DR STE 211
FAYETTEVILLE GA
30214-1578
US

V. Phone/Fax

Practice location:
  • Phone: 470-481-2020
  • Fax:
Mailing address:
  • Phone: 470-481-2020
  • Fax: 770-703-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number70849
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number70849
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number70849
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number70849
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: