Healthcare Provider Details

I. General information

NPI: 1528493434
Provider Name (Legal Business Name): BOLANLE GEORGE BSMT(AMT), MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5181 PAT WILEY DR
POWDER SPRINGS GA
30127-2457
US

IV. Provider business mailing address

233 MITCHELL ST SW SUITE 310
ATLANTA GA
30303-3304
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-4557
  • Fax:
Mailing address:
  • Phone: 404-819-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number154643
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number154643
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code246ZB0600X
TaxonomyBiostatiscian
License Number154643
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: