Provider Demographics
NPI:1891835021
Name:PHILLIP L. POTTER, MD, FACOG, PC
Entity Type:Organization
Organization Name:PHILLIP L. POTTER, MD, FACOG, PC
Other - Org Name:PHILLIP L. POTTER, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-352-5119
Mailing Address - Street 1:1938 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1267
Mailing Address - Country:US
Mailing Address - Phone:404-352-5119
Mailing Address - Fax:404-352-5330
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 504
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-819-8211
Practice Address - Fax:770-819-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00463163BMedicaid
GA=========OtherTAX ID #
GA00463163BMedicaid
16BDDGRMedicare ID - Type Unspecified