Provider Demographics
NPI:1245205442
Name:PEACHTREE NEUROLOGICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:PEACHTREE NEUROLOGICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-351-2270
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 4045
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-351-2270
Mailing Address - Fax:404-352-1969
Practice Address - Street 1:95 COLLIER RD NW
Practice Address - Street 2:SUITE 4045
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1796
Practice Address - Country:US
Practice Address - Phone:404-351-2270
Practice Address - Fax:404-352-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2191Medicare ID - Type Unspecified