Provider Demographics
NPI:1184831364
Name:HAILEY, BRODY, CASEY & WRAY, M.D., P.C.
Entity Type:Organization
Organization Name:HAILEY, BRODY, CASEY & WRAY, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-525-7409
Mailing Address - Street 1:1218 WEST PACES FERRY ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2306
Mailing Address - Country:US
Mailing Address - Phone:404-525-7409
Mailing Address - Fax:404-522-0608
Practice Address - Street 1:1218 WEST PACES FERRY ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2306
Practice Address - Country:US
Practice Address - Phone:404-525-7409
Practice Address - Fax:404-522-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55000141AMedicaid
GAGRP1081Medicare ID - Type Unspecified