Provider Demographics
NPI:1730491473
Name:PRO-MED OF ATLANTA, PC
Entity Type:Organization
Organization Name:PRO-MED OF ATLANTA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-676-6000
Mailing Address - Street 1:4646 N SHALLOWFORD RD
Mailing Address - Street 2:#400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6308
Mailing Address - Country:US
Mailing Address - Phone:770-676-6000
Mailing Address - Fax:770-392-9805
Practice Address - Street 1:4646 NORTH SHALLOWFORD ROAD
Practice Address - Street 2:#400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-676-6000
Practice Address - Fax:770-392-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT2218116208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty