Healthcare Provider Details

I. General information

NPI: 1619003902
Provider Name (Legal Business Name): BCGP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 KILLIAN HILL RD SW BUILDING A, SUITE B
LILBURN GA
30047-3102
US

IV. Provider business mailing address

976 KILLIAN HILL RD SW BUILDING A, SUITE B
LILBURN GA
30047-3102
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-6400
  • Fax:
Mailing address:
  • Phone: 770-923-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number052456
License Number StateGA

VIII. Authorized Official

Name: DR. GEORGE KATSITADZE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 770-923-6400