Healthcare Provider Details

I. General information

NPI: 1215587670
Provider Name (Legal Business Name): IMED SURGICAL OF ATLANTA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 CRABAPPLE RD STE 105B
ROSWELL GA
30075-2456
US

IV. Provider business mailing address

PO BOX 1970
NEW YORK NY
10156-1970
US

V. Phone/Fax

Practice location:
  • Phone: 404-480-4886
  • Fax: 917-791-9672
Mailing address:
  • Phone: 212-223-0716
  • Fax: 917-791-9672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER R MYERS
Title or Position: CLINICAL COMPLIANCE MANAGER
Credential:
Phone: 212-223-0716