Healthcare Provider Details

I. General information

NPI: 1598704678
Provider Name (Legal Business Name): MICHAEL JEFFERY O'NEILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

1365 CLIFTON ROAD
ATLANTA GA
30322-1064
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7750
  • Fax: 770-793-7755
Mailing address:
  • Phone: 404-778-7717
  • Fax: 404-778-7466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30175
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number30175
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: