Provider Demographics
NPI:1356441737
Name:TAYLOR, BERNARD G (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:G
Last Name:TAYLOR
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 1:11 UPPER RIVERDALE RD, SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274
Mailing Address - Country:US
Mailing Address - Phone:770-897-7107
Mailing Address - Fax:770-897-7109
Practice Address - Street 1:11 UPPER RIVERDALE RD, SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:770-897-7107
Practice Address - Fax:770-897-7109
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4582207R00000X
GA061007208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183507602Medicaid
TX8J1114Medicare ID - Type Unspecified
TX183507602Medicaid