Provider Demographics
NPI:1205008489
Name:RICHARD MATTISON, MD LLC
Entity Type:Organization
Organization Name:RICHARD MATTISON, MD LLC
Other - Org Name:TUXEDO AESTHETIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CRAWFORD
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:404-812-0211
Mailing Address - Street 1:3833 ROSWELL RD NE
Mailing Address - Street 2:SUITE #116
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4432
Mailing Address - Country:US
Mailing Address - Phone:404-812-0211
Mailing Address - Fax:404-812-9011
Practice Address - Street 1:3833 ROSWELL RD NE
Practice Address - Street 2:SUITE #116
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4432
Practice Address - Country:US
Practice Address - Phone:404-812-0211
Practice Address - Fax:404-812-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011627Medicare UPIN