Provider Demographics
NPI:1417240490
Name:GEORGIA DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:GEORGIA DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:GEORGIA PUBLIC HEALTH LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMISSIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-657-2700
Mailing Address - Street 1:2 PEACHTREE STREET NW
Mailing Address - Street 2:15TH FLOOR
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3142
Mailing Address - Country:US
Mailing Address - Phone:404-657-2700
Mailing Address - Fax:404-657-2715
Practice Address - Street 1:1749 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4005
Practice Address - Country:US
Practice Address - Phone:404-327-7900
Practice Address - Fax:404-327-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-121291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory