Provider Demographics
NPI:1346218021
Name:MOREHEAD, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:MOREHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465446
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042-5446
Mailing Address - Country:US
Mailing Address - Phone:770-237-1561
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:1170 CLEVELAND AVE
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-1700
Practice Address - Fax:770-237-1124
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017243207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40693Medicare UPIN
GA05BDDCTMedicare ID - Type UnspecifiedGA MEDICARE PROVIDER #