Provider Demographics
NPI:1376642777
Name:POTTER, PHILLIP L (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:L
Last Name:POTTER
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 1:1700 HOSPITAL SOUTH DR
Mailing Address - Street 2:SUITE 504
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6810
Mailing Address - Country:US
Mailing Address - Phone:770-819-9211
Mailing Address - Fax:770-819-9616
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 504
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-819-9211
Practice Address - Fax:770-819-9616
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034220207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00463163BMedicaid
GA00463163BMedicaid
GAA84695Medicare UPIN