Provider Demographics
NPI:1568670180
Name:ROSENTHAL, CLARK AND MATSURRA
Entity Type:Organization
Organization Name:ROSENTHAL, CLARK AND MATSURRA
Other - Org Name:ATLANTA VASCULAR SPECIALISTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-524-0095
Mailing Address - Street 1:315 BOULEVARD NE
Mailing Address - Street 2:N.E. 412
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1200
Mailing Address - Country:US
Mailing Address - Phone:404-524-0095
Mailing Address - Fax:404-658-9558
Practice Address - Street 1:315 BOULEVARD
Practice Address - Street 2:N.E. 412
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1264
Practice Address - Country:US
Practice Address - Phone:404-524-0095
Practice Address - Fax:404-658-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055001472AMedicaid
GAGRP3120Medicare PIN