Healthcare Provider Details

I. General information

NPI: 1578095741
Provider Name (Legal Business Name): MICHELLE PICON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 CHURCH ST NE STE 220
MARIETTA GA
30060-1116
US

IV. Provider business mailing address

699 CHURCH ST NE STE 220
MARIETTA GA
30060-1116
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-8505
  • Fax: 770-693-7387
Mailing address:
  • Phone: 770-422-8505
  • Fax: 770-693-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number88475
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: