Provider Demographics
NPI:1467449926
Name:GEORGIA HEART SPECIALISTS, LLC
Entity Type:Organization
Organization Name:GEORGIA HEART SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-786-0077
Mailing Address - Street 1:4140 TATE ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2562
Mailing Address - Country:US
Mailing Address - Phone:770-786-0077
Mailing Address - Fax:770-786-8750
Practice Address - Street 1:4140 TATE ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2562
Practice Address - Country:US
Practice Address - Phone:770-786-0077
Practice Address - Fax:770-786-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00408614FMedicaid
GA00408614FMedicaid
GAGRP3382Medicare PIN