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NPI Code Detail

MEDICARE: JASON L KONZELMANN MD

MEDICARE: JASON L KONZELMANN 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
1207P00000XEmergency Medicine Physician59990GA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1202I935064OTHERGAMEDICARE OF GA

General Provider Information

NPI Number : 1891845590
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON L KONZELMANN MD
Provider Business Mailing Address
First Line : P.O. BOX 6002
Second Line :
City : URBANA
State : IL
Zip : 61803-6002
Country : US
Telephone Number : 217-326-8300
Fax Number : 217-326-2856
Provider Business Practice Location Address
First Line : 743 SPRING ST NE
Second Line :
City : GAINESVILLE
State : GA
Zip : 30501-3899
Country : US
Telephone Number : 678-357-9327
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/12/2007
Last Update Date : 01/30/2019

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