Provider Demographics
NPI:1437170347
Name:GLENEAGLES SURGERY, PC
Entity Type:Organization
Organization Name:GLENEAGLES SURGERY, PC
Other - Org Name:GERMAN M. REYES, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:PIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-506-2080
Mailing Address - Street 1:1215 EAGLES LANDING PKWY
Mailing Address - Street 2:#105
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7279
Mailing Address - Country:US
Mailing Address - Phone:770-506-2080
Mailing Address - Fax:770-506-2767
Practice Address - Street 1:1215 EAGLES LANDING PKWY
Practice Address - Street 2:#105
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7279
Practice Address - Country:US
Practice Address - Phone:770-506-2080
Practice Address - Fax:770-506-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00313288CMedicaid
GA00313288CMedicaid