Healthcare Provider Details

I. General information

NPI: 1174274013
Provider Name (Legal Business Name): METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SHILOH RD NW STE 660
KENNESAW GA
30144-7158
US

IV. Provider business mailing address

1179 STATE ST NW
ATLANTA GA
30318-5331
US

V. Phone/Fax

Practice location:
  • Phone: 404-913-2891
  • Fax: 770-648-2908
Mailing address:
  • Phone: 301-367-2187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHENELLE WILSON
Title or Position: OWNER
Credential: MD
Phone: 404-913-2891