Healthcare Provider Details

I. General information

NPI: 1700023330
Provider Name (Legal Business Name): MICHEL JEANNOT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHEL JEANNOT MD

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 TARA COMMONS DR
LOGANVILLE GA
30052-8018
US

IV. Provider business mailing address

101 TARA COMMONS DR
LOGANVILLE GA
30052-8018
US

V. Phone/Fax

Practice location:
  • Phone: 678-928-9700
  • Fax: 770-466-1585
Mailing address:
  • Phone: 678-928-9700
  • Fax: 770-466-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number200901094
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number065686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: