Healthcare Provider Details

I. General information

NPI: 1619847662
Provider Name (Legal Business Name): IBRAHIM KHAIRY FAYED ELSHAMLY SC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 ATLANTA ST SE STE 204
MARIETTA GA
30060-1977
US

IV. Provider business mailing address

55 ATLANTA ST SE STE 204
MARIETTA GA
30060-1977
US

V. Phone/Fax

Practice location:
  • Phone: 678-517-3428
  • Fax: 770-485-1534
Mailing address:
  • Phone: 678-517-3428
  • Fax: 770-485-1534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number25341
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: