Healthcare Provider Details

I. General information

NPI: 1255737599
Provider Name (Legal Business Name): MR. JOHN GEORGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 S OYSTER BAY RD
PLAINVIEW NY
11803-3323
US

IV. Provider business mailing address

5555 GLENRIDGE CONNECTOR STE 700
ATLANTA GA
30342-4758
US

V. Phone/Fax

Practice location:
  • Phone: 516-537-9061
  • Fax: 516-537-9061
Mailing address:
  • Phone: 678-956-6531
  • Fax: 678-567-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number018054-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018054-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: