Provider Demographics
NPI:1639331150
Name:SOUTH ATLANTA NEUROLOGY & PAIN CLINIC, PC
Entity Type:Organization
Organization Name:SOUTH ATLANTA NEUROLOGY & PAIN CLINIC, PC
Other - Org Name:OPEN MRI OF SANPC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:BYUNG-IL
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-507-7359
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6198
Mailing Address - Country:US
Mailing Address - Phone:770-507-7359
Mailing Address - Fax:770-507-8390
Practice Address - Street 1:1040 EAGLES LANDING PKWY
Practice Address - Street 2:STE 102
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9073
Practice Address - Country:US
Practice Address - Phone:770-507-7359
Practice Address - Fax:770-507-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044899174400000X
2084N0400X, 2084P2900X, 2085D0003X, 2085N0700X, 2085R0202X, 2085R0203X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000783989FMedicaid
GA1174554455OtherINDIVIDUAL NPI #
GAE48180Medicare UPIN
GA000783989FMedicaid
GA13BDDDKMedicare PIN