=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265995724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA UROLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 12/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 HILLANDALE DR STE 110
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-205-8455
-----------------------------------------------------
Fax | 678-284-4078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 BRANNAN RD
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-284-4049
-----------------------------------------------------
Fax | 678-284-4078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE DIRECTOR
-----------------------------------------------------
Name | CHRISTI G KIRKLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-284-4049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------