Healthcare Provider Details

I. General information

NPI: 1427503986
Provider Name (Legal Business Name): 404 GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 MOUNT VERNON HWY NE SUITE 120
SANDY SPRINGS GA
30328-4274
US

IV. Provider business mailing address

755 MOUNT VERNON HWY NE SUITE 120
SANDY SPRINGS GA
30328-4274
US

V. Phone/Fax

Practice location:
  • Phone: 770-500-5600
  • Fax: 404-393-6788
Mailing address:
  • Phone: 770-500-5600
  • Fax: 404-393-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN M MCGREGOR
Title or Position: PRACTICE ADMIN
Credential:
Phone: 770-500-5600