Provider Demographics
NPI:1508284175
Name:INTERVENTIONAL INSTITUTE OF GEORGIA
Entity Type:Organization
Organization Name:INTERVENTIONAL INSTITUTE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:770-820-9222
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-0955
Mailing Address - Country:US
Mailing Address - Phone:770-506-4007
Mailing Address - Fax:678-246-5191
Practice Address - Street 1:7130 MOUNT ZION BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2566
Practice Address - Country:US
Practice Address - Phone:770-506-4007
Practice Address - Fax:678-246-5191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043894213ER0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000757314HMedicaid
GAG35635Medicare UPIN