Healthcare Provider Details

I. General information

NPI: 1114018835
Provider Name (Legal Business Name): JOHN T CHRYSSOCHOOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S 8TH ST STE 301
GRIFFIN GA
30224
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-229-6072
  • Fax: 770-229-2111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number044900
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: