Provider Demographics
NPI:1659616589
Name:PHYSICIAN SPECIALISTS OF ATLANTA
Entity Type:Organization
Organization Name:PHYSICIAN SPECIALISTS OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-531-9992
Mailing Address - Street 1:PO BOX 421876
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-8876
Mailing Address - Country:US
Mailing Address - Phone:404-531-9992
Mailing Address - Fax:404-531-9901
Practice Address - Street 1:100 GLENRIDGE POINT PKWY NE
Practice Address - Street 2:STE 530
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1442
Practice Address - Country:US
Practice Address - Phone:404-531-9992
Practice Address - Fax:404-531-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty