=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083768691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHTREE GYNECOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 PEACHTREE ST NW 650
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-539-5980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 PEACHTREE ST NW 650
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-539-5980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNERPRESIDENT
-----------------------------------------------------
Name | MRS. ANNE K WISKIND
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 678-539-5980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 029013
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------