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General NPI Number Information
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NPI Number | 1770942856
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Entity Type | Organization
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Legal Business Name | GEORGIA UROLOGY PEDIATRIC LLC
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Dates
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Enumeration Date | 02/17/2016
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Last Update Date | 02/17/2016
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Provider Practice Location Address
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Address Line | 5730 GLENRIDGE DR STE 200
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City | ATLANTA
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State | GA
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Zip | 30328-6141
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Country | US
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Telephone | 404-256-1844
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Fax | 404-252-5642
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Provider Business Mailing Address
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Address Line | 1930 BRANNAN RD
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City | MCDONOUGH
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State | GA
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Zip | 30253-4310
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Country | US
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Telephone | 678-284-4040
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Fax | 678-284-4076
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. MARK A HABER
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Credential | M.D.
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Telephone | 678-284-4040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2088P0231X
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Taxonomy Name | Pediatric Urology Physician
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License Number |
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License Number State |
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