Provider Demographics
NPI:1174274013
Name:METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:METRO ATLANTA UROLOGY AND PELVIC HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-913-2891
Mailing Address - Street 1:1179 STATE ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5331
Mailing Address - Country:US
Mailing Address - Phone:301-367-2187
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW STE 660
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7158
Practice Address - Country:US
Practice Address - Phone:404-913-2891
Practice Address - Fax:770-648-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty