Healthcare Provider Details

I. General information

NPI: 1669702296
Provider Name (Legal Business Name): MELVIN G PERRY JR MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 HERITAGE LAKES DR SW
MABLETON GA
30126-1248
US

IV. Provider business mailing address

PO BOX 1339
MABLETON GA
30126-1005
US

V. Phone/Fax

Practice location:
  • Phone: 770-745-3491
  • Fax: 770-745-3491
Mailing address:
  • Phone: 770-745-3491
  • Fax: 770-745-3491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MELVIN PERRY
Title or Position: OWNER
Credential: MD
Phone: 770-745-3491