Healthcare Provider Details

I. General information

NPI: 1912196775
Provider Name (Legal Business Name): GEORGIA PULMONARY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TREE LN SUITE 200
SNELLVILLE GA
30078-2016
US

IV. Provider business mailing address

1800 TREE LN SUITE 200
SNELLVILLE GA
30078-2016
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-0367
  • Fax: 770-979-1830
Mailing address:
  • Phone: 770-979-0367
  • Fax: 770-979-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36567
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36567
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number36567
License Number StateGA

VIII. Authorized Official

Name: MRS. TERRI L MCCLESKEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-979-2062