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General NPI Number Information
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NPI Number | 1073720959
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Entity Type | Organization
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Legal Business Name | EASTSIDE UROLOGY
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2121 FOUNTAIN DR SUITE D
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City | SNELLVILLE
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State | GA
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Zip | 30078-7023
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Country | US
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Telephone | 770-736-8368
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Fax | 770-736-8410
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Provider Business Mailing Address
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Address Line | 2121 FOUNTAIN DR
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City | SNELLVILLE
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State | GA
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Zip | 30078-7023
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Country | US
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Telephone | 770-736-8368
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Fax | 770-736-8410
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Authorized Official
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Title or Position | DIRECTOR OF BILLING
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Name | CAROLYN L VICKERS
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Credential |
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Telephone | 770-736-8368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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