MEDICARE: PENNY M FORMAN BLITZER MD

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	208000000X	Pediatrics Physician	0050077	GA

General Provider Information

NPI Number	:	1083664288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY M FORMAN BLITZER MD

Provider Business Mailing Address
First Line	:	4190 FALLS RIDGE DR
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30022-8490
Country	:	US
Telephone Number	:	770-674-2585
Fax Number	:	770-476-1674

Provider Business Practice Location Address
First Line	:	4310 JOHNS CREEK PKWY
Second Line	:	SUITE 150
City	:	SUWANEE
State	:	GA
Zip	:	30024-6091
Country	:	US
Telephone Number	:	770-476-4020
Fax Number	:	770-476-1674

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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