Provider Demographics
NPI:1497971329
Name:GEORGIA UROLOGY PA
Entity Type:Organization
Organization Name:GEORGIA UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-284-4049
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:33 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE 105
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2626
Practice Address - Country:US
Practice Address - Phone:770-991-0020
Practice Address - Fax:770-994-9729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA UROLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-18
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D0902137OtherCLIA
GA0879130020Medicare NSC
GAGRP1552Medicare PIN