Provider Demographics
NPI:1629000195
Name:GENERAL AND THORACIC SURGERY OF GEORGIA,LLC
Entity Type:Organization
Organization Name:GENERAL AND THORACIC SURGERY OF GEORGIA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-762-5037
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:ERIN OFFICE PARK # 11
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-274-1114
Mailing Address - Fax:478-274-1016
Practice Address - Street 1:2400 BELLEVUE RD
Practice Address - Street 2:ERIN OFFICE PARK # 11
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2885
Practice Address - Country:US
Practice Address - Phone:478-274-1114
Practice Address - Fax:478-274-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7754Medicare PIN