Provider Demographics
NPI:1073782058
Name:SOUTH ATLANTA MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTH ATLANTA MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICKY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BATTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-768-4626
Mailing Address - Street 1:1029 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-6719
Mailing Address - Country:US
Mailing Address - Phone:404-768-4626
Mailing Address - Fax:404-768-4631
Practice Address - Street 1:1029 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6719
Practice Address - Country:US
Practice Address - Phone:404-768-4626
Practice Address - Fax:404-768-4631
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH ATLANTA MEDICAL ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-25
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00508483GMedicaid
GA00508483GMedicaid
GA11BDPGTMedicare PIN
GA511G700388Medicare PIN