Provider Demographics
NPI:1952587354
Name:ATLANTA NEUROSCIENCE ASSOCIATES LLC
Entity Type:Organization
Organization Name:ATLANTA NEUROSCIENCE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KOZINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-994-5176
Mailing Address - Street 1:261 MEDICAL WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2522
Mailing Address - Country:US
Mailing Address - Phone:770-994-5176
Mailing Address - Fax:770-994-2954
Practice Address - Street 1:261 MEDICAL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2522
Practice Address - Country:US
Practice Address - Phone:770-994-5176
Practice Address - Fax:770-994-2954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13BDDKRMedicare PIN
GAD29978Medicare UPIN