Provider Demographics
NPI:1821019076
Name:GEORGIA UROLOGY PEDIATRIC LLC
Entity Type:Organization
Organization Name:GEORGIA UROLOGY PEDIATRIC LLC
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 1:5445 MERIDIAN MARKS RD NE
Practice Address - Street 2:SUITE 420
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:404-252-5206
Practice Address - Fax:404-252-1268
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA UROLOGY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-22
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty