Healthcare Provider Details

I. General information

NPI: 1295382778
Provider Name (Legal Business Name): ADVANCED UROLOGY INSTITUTE OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 CHURCH STREET EXT NE STE 200
MARIETTA GA
30060-7913
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax: 678-666-5201
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-666-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BEEMAL SHAH
Title or Position: CEO
Credential:
Phone: 706-951-8657