Provider Demographics
NPI:1891716049
Name:GEORGIA UROLOGY AMBULATORY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA UROLOGY AMBULATORY SURGICAL CENTER 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 1:2685 MILSCOTT DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5906
Practice Address - Country:US
Practice Address - Phone:404-292-3727
Practice Address - Fax:404-294-9674
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
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1025964OtherCLIA