=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639499627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA UROLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2010
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4298 ATLANTA RD. SE SUITE 305
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-429-9100
-----------------------------------------------------
Fax | 770-429-1391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 BRANNAN RD
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-284-4040
-----------------------------------------------------
Fax | 678-284-4076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DAN FELLNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-284-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------