Provider Demographics
NPI:1245965813
Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Entity type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WHITMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-413-1930
Mailing Address - Street 1:PO BOX 3996
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30302-3996
Mailing Address - Country:US
Mailing Address - Phone:404-413-1930
Mailing Address - Fax:404-413-1955
Practice Address - Street 1:141 PIEDMONT AVE NE STE D
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2417
Practice Address - Country:US
Practice Address - Phone:404-413-1930
Practice Address - Fax:404-413-1955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639373426OtherNPI