Provider Demographics
NPI:1457500837
Name:BRENDA FITZGERALD M.D., P.C.
Entity Type:Organization
Organization Name:BRENDA FITZGERALD M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-5828
Mailing Address - Street 1:523 DIXIE ST
Mailing Address - Street 2:STE 3
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3870
Mailing Address - Country:US
Mailing Address - Phone:770-838-5828
Mailing Address - Fax:770-838-5831
Practice Address - Street 1:523 DIXIE ST
Practice Address - Street 2:STE 3
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3870
Practice Address - Country:US
Practice Address - Phone:770-838-5828
Practice Address - Fax:770-838-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAD29480305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29480Medicare UPIN