Provider Demographics
NPI:1598796195
Name:ATLANTA ALLERGY & ASTHMA, PA
Entity Type:Organization
Organization Name:ATLANTA ALLERGY & ASTHMA, PA
Other - Org Name:ATLANTA ALLERGY & ASTHMA, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERSTREET
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:770-952-8612
Mailing Address - Street 1:8200 ROBERTS DR STE 450
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4115
Mailing Address - Country:US
Mailing Address - Phone:770-952-8612
Mailing Address - Fax:678-803-6944
Practice Address - Street 1:114 TOWN PARK DRIVE NW
Practice Address - Street 2:SUITE 240
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5802
Practice Address - Country:US
Practice Address - Phone:770-485-3723
Practice Address - Fax:678-803-6944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X
GA207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034675AMedicare UPIN