Provider Demographics
NPI:1407116056
Name:AMNESTIC, LLC
Entity Type:Organization
Organization Name:AMNESTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANI
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SANUSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-660-8505
Mailing Address - Street 1:2500 DALLAS HWY SW STE 202
Mailing Address - Street 2:BOX 160
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-7505
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-9390
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:706-660-8505
Practice Address - Fax:706-660-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036450207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF34797Medicare UPIN