Provider Demographics
NPI:1235177379
Name:EMORY MEDICAL AFFILIATES, INC
Entity Type:Organization
Organization Name:EMORY MEDICAL AFFILIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CASTELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-778-5232
Mailing Address - Street 1:101 W PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2533
Mailing Address - Country:US
Mailing Address - Phone:404-778-7525
Mailing Address - Fax:404-778-7823
Practice Address - Street 1:1845 SATELLITE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4061
Practice Address - Country:US
Practice Address - Phone:404-778-5220
Practice Address - Fax:770-995-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2002000727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4973Medicare ID - Type Unspecified