=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790118131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMY MEISEL MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2013
-----------------------------------------------------
Last Update Date | 11/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4904 TIMBER RIDGE DR SUITE 305
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-501-5420
-----------------------------------------------------
Fax | 678-501-5429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1579 MONROE DR NE STE F SUITE F602
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-501-5420
-----------------------------------------------------
Fax | 678-501-5429
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEREMY MEISEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 678-501-5420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 052786
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------