MEDICARE: GEORGIA UROLOGY PA

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	208800000X	Urology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11D1020143	OTHER	GA	CLIA

General Provider Information

NPI Number	:	1063637254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA UROLOGY PA

Provider Business Mailing Address
First Line	:	1930 BRANNAN RD
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-4310
Country	:	US
Telephone Number	:	678-284-4040
Fax Number	:	678-284-4076

Provider Business Practice Location Address
First Line	:	550 PEACHTREE ST NE
Second Line	:	SUITE 1150
City	:	ATLANTA
State	:	GA
Zip	:	30308-2247
Country	:	US
Telephone Number	:	404-222-0292
Fax Number	:	404-222-0452

Authorized Official
Title or Position	:	CEO
Name	:	DAN FELLNER
Credential	:
Telephone Number	:	678-205-8360

Provider Enumeration Date	:	04/15/2007
Last Update Date	:	05/06/2026

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