Healthcare Provider Details

I. General information

NPI: 1104294743
Provider Name (Legal Business Name): GEORGIA UROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LAKE HEARN DR NE STE 500
SANDY SPRINGS GA
30319-6405
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-1844
  • Fax: 404-252-5642
Mailing address:
  • Phone: 678-284-4040
  • Fax: 678-284-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAN FELLNER
Title or Position: CEO
Credential:
Phone: 678-205-8360