Provider Demographics
NPI:1902337637
Name:PREMIER CARDIOTHORACIC SURGERY, LLC
Entity Type:Organization
Organization Name:PREMIER CARDIOTHORACIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:FADY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-955-1804
Mailing Address - Street 1:688 WALNUT ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2677
Mailing Address - Country:US
Mailing Address - Phone:478-955-1804
Mailing Address - Fax:
Practice Address - Street 1:688 WALNUT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2677
Practice Address - Country:US
Practice Address - Phone:478-955-1804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043813208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty