Healthcare Provider Details

I. General information

NPI: 1174335145
Provider Name (Legal Business Name): CENTRAL GEORGIA ADRENAL AND REPRODUCTIVE ENDOCRINOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 RACETRACK RD
MCDONOUGH GA
30252-1022
US

IV. Provider business mailing address

121 LIGHTHORSE BLVD
MCDONOUGH GA
30252-2998
US

V. Phone/Fax

Practice location:
  • Phone: 801-657-8137
  • Fax: 801-657-8137
Mailing address:
  • Phone: 801-657-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number State

VIII. Authorized Official

Name: HANSEL MARK RAYNER
Title or Position: OWNER
Credential: PA-C
Phone: 470-317-3855