MEDICARE: IDEAL GYNECOLOGY 2, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	40540	GA

General Provider Information

NPI Number	:	1003343963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL GYNECOLOGY 2, LLC

Provider Business Mailing Address
First Line	:	PO BOX 468329
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31146-8329
Country	:	US
Telephone Number	:	404-943-0205
Fax Number	:	404-943-0209

Provider Business Practice Location Address
First Line	:	3200 DOWNWOOD CIR NW STE 220
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30327-1611
Country	:	US
Telephone Number	:	470-312-3696
Fax Number	:	866-278-2622

Authorized Official
Title or Position	:	PAYER RELATIONS LIAISON
Name	:	SHELLEY DEPP
Credential	:
Telephone Number	:	770-579-2626

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	05/22/2017

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