Provider Demographics
NPI:1346209764
Name:SOUTH ATLANTA HEMATOLOGY ONCOLOGY PC
Entity Type:Organization
Organization Name:SOUTH ATLANTA HEMATOLOGY ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-996-0622
Mailing Address - Street 1:253 UPPER RIVERDALE RD SW STE C
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4945
Mailing Address - Country:US
Mailing Address - Phone:770-996-0622
Mailing Address - Fax:770-996-1492
Practice Address - Street 1:253 UPPER RIVERDALE RD SW STE C
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4945
Practice Address - Country:US
Practice Address - Phone:770-996-0622
Practice Address - Fax:770-996-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6884Medicare PIN