Healthcare Provider Details

I. General information

NPI: 1073598488
Provider Name (Legal Business Name): MARIETTA NEUROLOGY AND HEADACHE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 CANTON RD STE 400
MARIETTA GA
30060-7298
US

IV. Provider business mailing address

780 CANTON RD STE 400
MARIETTA GA
30060-7298
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-3602
  • Fax: 770-421-6115
Mailing address:
  • Phone: 770-422-3602
  • Fax: 770-421-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS M HOLMES
Title or Position: MD MANAGING PARTNER
Credential: MD
Phone: 770-422-3602