Provider Demographics
NPI:1932677812
Name:FORNAH, ALFRED (CSCM)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:FORNAH
Suffix:
Gender:M
Credentials:CSCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 PACES FERRY RD SE STE 750
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4053
Mailing Address - Country:US
Mailing Address - Phone:770-694-1777
Mailing Address - Fax:678-981-4601
Practice Address - Street 1:2727 PACES FERRY RD SE STE 750
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4053
Practice Address - Country:US
Practice Address - Phone:770-694-1777
Practice Address - Fax:678-981-4601
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-2053374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA82-4816080Medicaid