MEDICARE: MY CONCIERGE SURGERY 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	208600000X	Surgery Physician	055150	GA

General Provider Information

NPI Number	:	1316338197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY CONCIERGE SURGERY LLC

Provider Business Mailing Address
First Line	:	1233 SPRING PARK DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2410
Country	:	US
Telephone Number	:	404-754-0922
Fax Number	:	404-756-2444

Provider Business Practice Location Address
First Line	:	1233 SPRING PARK DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-2410
Country	:	US
Telephone Number	:	404-754-0922
Fax Number	:	404-756-2444

Authorized Official
Title or Position	:	CEO
Name	:	DR. AHMAD IBN NURIDDIN
Credential	:	M.D.
Telephone Number	:	404-754-0922

Provider Enumeration Date	:	02/14/2015
Last Update Date	:	02/14/2015

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