Provider Demographics
NPI:1770821001
Name:GEORGIA UROLOGY PA
Entity Type:Organization
Organization Name:GEORGIA UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-284-4049
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:SUITE M-245
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:678-205-8211
Practice Address - Fax:404-554-1794
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA UROLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-21
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1552Medicare PIN