Provider Demographics
NPI:1811668593
Name:PRIME REGEN DECATUR
Entity type:Organization
Organization Name:PRIME REGEN DECATUR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT, SGI
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAUPT
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:470-292-3820
Mailing Address - Street 1:2680 LAWRENCEVILLE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2526
Mailing Address - Country:US
Mailing Address - Phone:470-292-3820
Mailing Address - Fax:
Practice Address - Street 1:2680 LAWRENCEVILLE HWY STE 101
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2526
Practice Address - Country:US
Practice Address - Phone:470-292-3820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty