=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992146146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2013
-----------------------------------------------------
Last Update Date | 07/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 CORPORATE CENTER DR STE 200
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-968-6460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 RENAISSANCE PKWY NE APT 304
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-2360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-788-3792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT PHYSICIAN
-----------------------------------------------------
Name | DR. CARLOS MIGUEL TELLECHEA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 305-788-3792
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------