Provider Demographics
NPI:1184633778
Name:NORTH ATLANTA UROLOGY ASSOC PC
Entity Type:Organization
Organization Name:NORTH ATLANTA UROLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIMMERSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-0424
Mailing Address - Street 1:631 PROFESSIONAL DR STE 490
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3370
Mailing Address - Country:US
Mailing Address - Phone:770-995-0424
Mailing Address - Fax:770-513-7334
Practice Address - Street 1:631 PROFESSIONAL DR STE 490
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-995-0424
Practice Address - Fax:770-513-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1101Medicare PIN
GA0365460002Medicare NSC