Provider Demographics
NPI:1972843084
Name:BUCKHEAD SURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:BUCKHEAD SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:COLQUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-350-7955
Mailing Address - Street 1:2061 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1427
Mailing Address - Country:US
Mailing Address - Phone:404-350-7955
Mailing Address - Fax:404-350-9115
Practice Address - Street 1:2061 PEACHTREE RD NE
Practice Address - Street 2:SUITE 300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1427
Practice Address - Country:US
Practice Address - Phone:404-350-7955
Practice Address - Fax:404-350-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41097208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20270G4314Medicare PIN