Provider Demographics
NPI:1154398709
Name:HORESH, LARRY (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:HORESH
Suffix:
Gender:M
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:PO BOX 116336
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6336
Mailing Address - Country:US
Mailing Address - Phone:912-352-8346
Mailing Address - Fax:912-352-1414
Practice Address - Street 1:4750 WATERS AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6200
Practice Address - Country:US
Practice Address - Phone:912-352-8346
Practice Address - Fax:912-355-1414
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0574812085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA308543732DMedicaid
SCG57481Medicaid
TN3852310Medicaid
GA308543732AMedicaid
GA7124808OtherAETNA PPO PROVIDER ID
GA308543732AMedicaid
GAP00727509Medicare PIN
GA308543732DMedicaid
GAF89049Medicare UPIN
GA94BFBLLMedicare ID - Type UnspecifiedGA MCARE PROVIDER ID