Provider Demographics
NPI:1508188558
Name:GEORGIA MOUNTAIN ENDOCRINOLOGY CORPORATION
Entity Type:Organization
Organization Name:GEORGIA MOUNTAIN ENDOCRINOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-556-9696
Mailing Address - Street 1:120 OAKSIDE CT
Mailing Address - Street 2:SUITE H
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2471
Mailing Address - Country:US
Mailing Address - Phone:404-556-9696
Mailing Address - Fax:
Practice Address - Street 1:120 OAKSIDE CT
Practice Address - Street 2:SUITE H
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2471
Practice Address - Country:US
Practice Address - Phone:404-556-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048322207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH89461Medicare UPIN