Provider Demographics
NPI: | 1538132733 |
---|---|
Name: | PIYASENA, HARISCHANDRA (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | HARISCHANDRA |
Middle Name: | |
Last Name: | PIYASENA |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1700 HOSPITAL SOUTH DR |
Mailing Address - Street 2: | SUITE 502 |
Mailing Address - City: | AUSTELL |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30106 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 678-741-2317 |
Mailing Address - Fax: | 678-741-2301 |
Practice Address - Street 1: | 1700 HOSPITAL SOUTH DR |
Practice Address - Street 2: | SUITE 502 |
Practice Address - City: | AUSTELL |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30106-6810 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-739-9555 |
Practice Address - Fax: | 770-732-8110 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-08 |
Last Update Date: | 2009-08-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 017078 | 174400000X, 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 000972265A | Medicaid | |
E58951 | Medicare UPIN | ||
10BBCMT | Medicare ID - Type Unspecified |