Provider Demographics
NPI:1013958511
Name:PEACHTREE UROLOGY, PC
Entity Type:Organization
Organization Name:PEACHTREE UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MAXWELL
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-355-7272
Mailing Address - Street 1:3525 PIEDMONT RD NE
Mailing Address - Street 2:SUITE 7-601
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1578
Mailing Address - Country:US
Mailing Address - Phone:404-842-5400
Mailing Address - Fax:404-848-1225
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 680
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-355-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028233208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5057Medicare PIN