Provider Demographics
NPI:1407062706
Name:PEACHTREE COLON AND RECTAL CLINIC
Entity Type:Organization
Organization Name:PEACHTREE COLON AND RECTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-351-2001
Mailing Address - Street 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 540
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-351-2001
Mailing Address - Fax:404-352-8418
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:SUITE 540
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-351-2001
Practice Address - Fax:404-352-8418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35712208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP347Medicare PIN