Provider Demographics
NPI:1093021172
Name:PEACHTREE CARDIOVASCULAR SURGEONS AT SAINT JOSEPH'S LLC
Entity Type:Organization
Organization Name:PEACHTREE CARDIOVASCULAR SURGEONS AT SAINT JOSEPH'S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:FREEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-579-1894
Mailing Address - Street 1:PO BOX 70547
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30007-0547
Mailing Address - Country:US
Mailing Address - Phone:770-579-1894
Mailing Address - Fax:770-579-1899
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:404-252-6104
Practice Address - Fax:404-257-1808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT JOSEPH MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-26
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101143AMedicaid
GA003101143AMedicaid