Provider Demographics
NPI:1295786234
Name:ERDELYAN, GREGORY L (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:ERDELYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 HOSPITAL DR.
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6381
Mailing Address - Country:US
Mailing Address - Phone:678-289-2003
Mailing Address - Fax:678-289-0191
Practice Address - Street 1:1104 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6381
Practice Address - Country:US
Practice Address - Phone:678-289-2003
Practice Address - Fax:678-289-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35864208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000508362FMedicaid
GAF33634Medicare UPIN
GA02BBGHHMedicare ID - Type Unspecified