Healthcare Provider Details

I. General information

NPI: 1669908992
Provider Name (Legal Business Name): IMMANUEL HSU D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 OLD JACKSON RD
MCDONOUGH GA
30252-3095
US

IV. Provider business mailing address

65 OLD JACKSON RD
MCDONOUGH GA
30252-3095
US

V. Phone/Fax

Practice location:
  • Phone: 678-490-0080
  • Fax: 678-490-0091
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number85753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: