Healthcare Provider Details

I. General information

NPI: 1669595526
Provider Name (Legal Business Name): GREGORY L. ERDELYAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 HOSPITAL DR
STOCKBRIDGE GA
30281-6381
US

IV. Provider business mailing address

1104 HOSPITAL DR
STOCKBRIDGE GA
30281-6381
US

V. Phone/Fax

Practice location:
  • Phone: 678-289-2003
  • Fax: 678-289-0191
Mailing address:
  • Phone: 678-289-2003
  • Fax: 678-289-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35864
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number35864
License Number StateGA

VIII. Authorized Official

Name: MRS. PIA MAGDALENE BERKS
Title or Position: BILLER
Credential:
Phone: 770-378-2449