Healthcare Provider Details

I. General information

NPI: 1417213109
Provider Name (Legal Business Name): EMERALD LOVELY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 SUGARLOAF PKWY STE 1200
LAWRENCEVILLE GA
30045-9459
US

IV. Provider business mailing address

2695 SUGARLOAF PKWY STE 1200
LAWRENCEVILLE GA
30045-9459
US

V. Phone/Fax

Practice location:
  • Phone: 678-444-7878
  • Fax: 888-571-6429
Mailing address:
  • Phone: 678-444-7878
  • Fax: 888-571-6429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD35230
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number87081
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: