=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255514899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIAN FOGLE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 01/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 69 JESSE HILL JR DR SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-616-5411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 69 JESSE HILL JR DR SE C/O CAROLE WEST, DEPT OF GYN/OB 4TH FLOOR
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-616-5411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 054277
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------