Provider Demographics
NPI:1073598488
Name:MARIETTA NEUROLOGY AND HEADACHE CENTER, PC
Entity Type:Organization
Organization Name:MARIETTA NEUROLOGY AND HEADACHE CENTER, PC
Other - Org Name:MARIETTA NEUROLOGICAL ASSOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-422-3602
Mailing Address - Street 1:780 CANTON RD
Mailing Address - Street 2:STE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7298
Mailing Address - Country:US
Mailing Address - Phone:770-422-3602
Mailing Address - Fax:770-421-6115
Practice Address - Street 1:780 CANTON RD
Practice Address - Street 2:STE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7298
Practice Address - Country:US
Practice Address - Phone:770-422-3602
Practice Address - Fax:770-421-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP850Medicare ID - Type Unspecified