Provider Demographics
NPI:1720075567
Name:WILEY, GENNIFER N (MD)
Entity Type:Individual
Prefix:
First Name:GENNIFER
Middle Name:N
Last Name:WILEY
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 1:3155 N POINT PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:SUITE 302
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:678-574-0943
Practice Address - Fax:678-574-0943
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47277207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000825437HMedicaid
GA000825437KMedicaid
GA000825437IMedicaid
GA000825437JMedicaid
GA000825437MMedicaid
GA000825437LMedicaid
GA000825437IMedicaid
GA000825437KMedicaid
GA05BDKQNMedicare PIN
GA000825437JMedicaid