Provider Demographics
NPI:1780853200
Name:ATLANTA MINIMALLY INVASIVE GYNECOLOGIC SURGERY CENTER,LLC
Entity Type:Organization
Organization Name:ATLANTA MINIMALLY INVASIVE GYNECOLOGIC SURGERY CENTER,LLC
Other - Org Name:ATLANTA MINIMALLY INVASIVE GYNECOLOGIC SURGERY CENTER,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FREEDOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-355-4885
Mailing Address - Street 1:105 COLLIER RD NW
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1710
Mailing Address - Country:US
Mailing Address - Phone:404-355-4885
Mailing Address - Fax:404-355-2210
Practice Address - Street 1:105 COLLIER RD NW
Practice Address - Street 2:SUITE 1010
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1710
Practice Address - Country:US
Practice Address - Phone:404-355-4885
Practice Address - Fax:404-355-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045895174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADA6300OtherMEDICARE RAILROAD
GAGRP4747Medicare PIN