Healthcare Provider Details

I. General information

NPI: 1639331150
Provider Name (Legal Business Name): SOUTH ATLANTA NEUROLOGY & PAIN CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EAGLES LANDING PKWY STE 102
STOCKBRIDGE GA
30281-9073
US

IV. Provider business mailing address

PO BOX 1198
FAYETTEVILLE GA
30214-6198
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-7359
  • Fax: 770-507-8390
Mailing address:
  • Phone: 770-507-7359
  • Fax: 770-507-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number044899
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRICE BYUNG-IL CHOI
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 770-507-7359