=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285806620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA SURGICENTER FOR WOMENS CHOICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2008
-----------------------------------------------------
Last Update Date | 03/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1874 PIEDMONT ROAD SUITE 570E
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-347-9191
-----------------------------------------------------
Fax | 404-745-9041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33296
-----------------------------------------------------
City | DECATUN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-0296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | TYRONE C MALLOY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-534-0035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 023086
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------