Provider Demographics
NPI:1376676486
Name:SOUTH ATLANTA PULMONARY GROUP
Entity Type:Organization
Organization Name:SOUTH ATLANTA PULMONARY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-466-6242
Mailing Address - Street 1:1136 CLEVELAND AVE
Mailing Address - Street 2:SUITE 519
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3618
Mailing Address - Country:US
Mailing Address - Phone:404-761-3525
Mailing Address - Fax:404-766-3696
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:SUITE 519
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-761-3525
Practice Address - Fax:404-766-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020396207R00000X, 207RP1001X
GA028704207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000179286CMedicaid
GA000330206BMedicaid
GA000330206BMedicaid
GAD28766Medicare UPIN
GA143542165AMedicare ID - Type UnspecifiedDR.AL-MULKI
GA331703920AMedicare ID - Type UnspecifiedDR.AKBIK