Provider Demographics
NPI:1891138640
Name:ROSE BRIGLEVICH, M.D., P.C.
Entity Type:Organization
Organization Name:ROSE BRIGLEVICH, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIGLEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-433-0434
Mailing Address - Street 1:3969 S COBB DR SE
Mailing Address - Street 2:#107
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6358
Mailing Address - Country:US
Mailing Address - Phone:770-433-0434
Mailing Address - Fax:770-433-0435
Practice Address - Street 1:3969 S COBB DR SE
Practice Address - Street 2:#107
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6358
Practice Address - Country:US
Practice Address - Phone:770-433-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29019Medicare UPIN