Provider Demographics
NPI:1255364600
Name:CARDIOLOGY SPECIALISTS OF GEORGIA LLC
Entity type:Organization
Organization Name:CARDIOLOGY SPECIALISTS OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FENSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-391-9980
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-391-9980
Mailing Address - Fax:229-391-9984
Practice Address - Street 1:907 18TH ST E
Practice Address - Street 2:SUITE 100
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3643
Practice Address - Country:US
Practice Address - Phone:229-391-9980
Practice Address - Fax:229-391-9984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057762207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF25404Medicare UPIN