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General NPI Number Information
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NPI Number | 1144220245
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Entity Type | Organization
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Legal Business Name | FAYETTE COMMUNITY ANESTHESIA
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Dates
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Enumeration Date | 07/29/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1984 PEACHTREE RD NW SUITE 515
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City | ATLANTA
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State | GA
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Zip | 30309-1298
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Country | US
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Telephone | 404-351-1745
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7836
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City | MARIETTA
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State | GA
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Zip | 30065-1836
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Country | US
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Telephone | 678-202-2060
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MR. MIKE KOLESAR
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Credential |
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Telephone | 404-351-1745
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State | GA
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