MEDICARE: GEORGIA UROLOGY AMBULATORY SURGERY CENTER SMYRNA 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1902784226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA UROLOGY AMBULATORY SURGERY CENTER SMYRNA LLC

Provider Business Mailing Address
First Line	:	1930 BRANNAN RD
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-4310
Country	:	US
Telephone Number	:	678-284-4040
Fax Number	:	678-284-4076

Provider Business Practice Location Address
First Line	:	4298 ATLANTA RD SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-6433
Country	:	US
Telephone Number	:	770-429-9100
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DANIEL S FELLNER
Credential	:
Telephone Number	:	678-205-8360

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	08/25/2025

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