Provider Demographics
NPI:1003343963
Name:IDEAL GYNECOLOGY 2, LLC
Entity Type:Organization
Organization Name:IDEAL GYNECOLOGY 2, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER RELATIONS LIAISON
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-579-2626
Mailing Address - Street 1:PO BOX 468329
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31146-8329
Mailing Address - Country:US
Mailing Address - Phone:404-943-0205
Mailing Address - Fax:404-943-0209
Practice Address - Street 1:3200 DOWNWOOD CIR NW STE 220
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1611
Practice Address - Country:US
Practice Address - Phone:470-312-3696
Practice Address - Fax:866-278-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40540207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty