Healthcare Provider Details

I. General information

NPI: 1487950275
Provider Name (Legal Business Name): PEACHTREE SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7742 SPALDING DR STE 115
NORCROSS GA
30092-4207
US

IV. Provider business mailing address

7742 SPALDING DR STE 115
NORCROSS GA
30092-4207
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-6529
  • Fax: 770-840-7464
Mailing address:
  • Phone: 678-691-6529
  • Fax: 770-840-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberF01331
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number238.000137
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberF01331
License Number StateGA

VIII. Authorized Official

Name: MR. JOHN WALKER
Title or Position: OWNER
Credential: CSA, CFA
Phone: 678-691-6529