Provider Demographics
NPI:1184756090
Name:PSYCH ATLANTA, P.C.
Entity type:Organization
Organization Name:PSYCH ATLANTA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BANOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-422-2009
Mailing Address - Street 1:1012 COGGINS PLACE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1306
Mailing Address - Country:US
Mailing Address - Phone:770-422-2009
Mailing Address - Fax:770-428-0330
Practice Address - Street 1:1012 COGGINS PLACE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1306
Practice Address - Country:US
Practice Address - Phone:770-422-2009
Practice Address - Fax:770-428-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2352Medicare ID - Type Unspecified