Provider Demographics
NPI:1629108964
Name:BRYAN DEMARCO
Entity Type:Organization
Organization Name:BRYAN DEMARCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DE MARCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-432-5326
Mailing Address - Street 1:3969 S COBB DR SE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3969 S COBB DR SE
Practice Address - Street 2:SUITE 206
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6358
Practice Address - Country:US
Practice Address - Phone:770-432-5326
Practice Address - Fax:770-432-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030987207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29273Medicare UPIN
GA16BBCDHMedicare ID - Type Unspecified