Provider Demographics
NPI:1376894683
Name:AGEWELL MEN'S INSTITUTE
Entity Type:Organization
Organization Name:AGEWELL MEN'S INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVEREL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-559-5834
Mailing Address - Street 1:3596 OLD MILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4465
Mailing Address - Country:US
Mailing Address - Phone:770-559-5834
Mailing Address - Fax:
Practice Address - Street 1:3596 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4465
Practice Address - Country:US
Practice Address - Phone:770-559-5834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035769208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty