Healthcare Provider Details

I. General information

NPI: 1518072800
Provider Name (Legal Business Name): SCOTT ASBURY KELLERMEYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

PO BOX 658
GAINESVILLE GA
30503-0658
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-9391
  • Fax: 770-533-4701
Mailing address:
  • Phone: 770-533-6511
  • Fax: 770-533-4786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101223420
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number59803
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: