Provider Demographics
NPI:1265402317
Name:PRICE, THEOLYN N (MD)
Entity type:Individual
Prefix:
First Name:THEOLYN
Middle Name:N
Last Name:PRICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HOSPITAL BLVD STE 420
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4919
Mailing Address - Country:US
Mailing Address - Phone:704-249-7327
Mailing Address - Fax:770-421-0228
Practice Address - Street 1:2500 HOSPITAL BLVD STE 420
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:704-249-7327
Practice Address - Fax:770-421-0228
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45827208600000X
FLME110622208G00000X
CO52769208G00000X
GA80819208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN003983700Medicaid
MNP00042740OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
WI35294500Medicaid
MN020001945Medicare PIN
H92304Medicare UPIN
WI35294500Medicaid