Provider Demographics
NPI:1356594709
Name:THOMAS W. BANTLY, M.D., P.C
Entity type:Organization
Organization Name:THOMAS W. BANTLY, M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BANTLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-738-7534
Mailing Address - Street 1:1700 TREE LANE ROAD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6782
Mailing Address - Country:US
Mailing Address - Phone:770-736-7534
Mailing Address - Fax:770-736-8627
Practice Address - Street 1:1700 TREE LANE ROAD
Practice Address - Street 2:SUITE 260
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:770-736-7534
Practice Address - Fax:770-736-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000275877BMedicaid
GA000275877BMedicaid
D28866Medicare UPIN