=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770842932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA MEDICAL CENTER INTERVENTIONAL NEUROLOGY ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2012
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 BOULEVARD NE SUITE 415
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-265-4400
-----------------------------------------------------
Fax | 404-265-4452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 BOULEVARD NE SUITE 415
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-265-4400
-----------------------------------------------------
Fax | 404-265-4452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP PMI OPS & FINANCE, TENET
-----------------------------------------------------
Name | MR. J. SCOTT RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-893-6960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------