MEDICARE: DR. ALYSSA GAMBLE 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	208000000X	Pediatrics Physician	062699	GA

General Provider Information

NPI Number	:	1528144839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALYSSA GAMBLE M.D.

Provider Business Mailing Address
First Line	:	4152 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1404
Country	:	US
Telephone Number	:	770-788-1077
Fax Number	:	770-788-0768

Provider Business Practice Location Address
First Line	:	4152 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1404
Country	:	US
Telephone Number	:	770-788-1077
Fax Number	:	770-788-0768

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

Provider Enumeration Date	:	10/29/2006
Last Update Date	:	09/07/2011

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