Healthcare Provider Details

I. General information

NPI: 1073059531
Provider Name (Legal Business Name): MARTIN BABAYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE ROAD
RIVERDALE GA
30274
US

IV. Provider business mailing address

5038 WICKFORD DR
PEACHTREE CORNERS GA
30096-2405
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8000
  • Fax:
Mailing address:
  • Phone: 516-469-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN241922
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number39693
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: