Provider Demographics
NPI:1679007108
Name:EAR NOSE AND THROAT FACIAL PLASTICS AND SLEEP DISORDER ASCLLC
Entity Type:Organization
Organization Name:EAR NOSE AND THROAT FACIAL PLASTICS AND SLEEP DISORDER ASCLLC
Other - Org Name:EAR NOSE & THROAT FACIAL PLASTICS & SLEEP DISORDER CENTER ASC LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOOKER
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:404-350-9200
Mailing Address - Street 1:601 PRYOR ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-2719
Mailing Address - Country:US
Mailing Address - Phone:404-350-9200
Mailing Address - Fax:404-529-9092
Practice Address - Street 1:601 PRYOR ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-350-9200
Practice Address - Fax:404-529-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000663891AMedicaid
GA1821164500OtherINDIVIDUAL NPI
GA000663891AMedicaid
GA511G701066Medicare PIN