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General NPI Number Information
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NPI Number | 1043409048
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Entity Type | Individual
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Provider Name | JEANIE PARK M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 05/17/2011
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Provider Practice Location Address
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Address Line | 550 PEACHTREE ST NE MOT 8TH FLOOR
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City | ATLANTA
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State | GA
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Zip | 30308-2208
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Country | US
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Telephone | 404-686-5038
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Fax | 404-686-4995
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Provider Business Mailing Address
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Address Line | 1670 CLAIRMONT RD RENAL/NEPHROLOGY AND HEMODIALYSIS MED (111)
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City | DECATUR
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State | GA
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Zip | 30033-4004
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Country | US
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Telephone | 404-321-6111
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Fax | 404-235-3049
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 061137
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License Number State | GA
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