MEDICARE: DR. PODALY UNG JAY M.D.

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	207R00000X	Internal Medicine Physician	052355	GA

General Provider Information

NPI Number	:	1306849013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PODALY UNG JAY M.D.

Provider Business Mailing Address
First Line	:	1431 WHITE CIR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-5801
Country	:	US
Telephone Number	:	770-424-2226
Fax Number	:	770-424-8787

Provider Business Practice Location Address
First Line	:	1431 WHITE CIR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-5801
Country	:	US
Telephone Number	:	770-424-2226
Fax Number	:	770-424-8787

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	10/07/2011

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