Provider Demographics
NPI:1649537416
Name:DEKALB NEUROLOGY GROUP, LLC
Entity type:Organization
Organization Name:DEKALB NEUROLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MABE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-508-4008
Mailing Address - Street 1:2665 N DECATUR RD
Mailing Address - Street 2:SUITE 540
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-508-4008
Mailing Address - Fax:404-508-4009
Practice Address - Street 1:2665 N DECATUR RD
Practice Address - Street 2:SUITE 540
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6149
Practice Address - Country:US
Practice Address - Phone:404-508-4008
Practice Address - Fax:404-508-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0557132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13BDDXXMedicaid
GAE88102Medicare UPIN