Provider Demographics
NPI:1518281864
Name:AGELESS MENS HEALTH
Entity Type:Organization
Organization Name:AGELESS MENS HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TEAH
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-205-3999
Mailing Address - Street 1:2941 PIEDMONT RD NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2784
Mailing Address - Country:US
Mailing Address - Phone:404-841-9445
Mailing Address - Fax:901-841-9446
Practice Address - Street 1:2941 PIEDMONT RD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2784
Practice Address - Country:US
Practice Address - Phone:404-841-9445
Practice Address - Fax:901-841-9446
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGELESS MENS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-16
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5765363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty