Provider Demographics
NPI:1164449146
Name:LAVELY, WILLIAM C (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:LAVELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5605 GLENRIDGE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:678-553-7783
Mailing Address - Fax:678-553-7793
Practice Address - Street 1:1000 JOHNSON FERRY ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-6323
Practice Address - Fax:404-303-3747
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2019-05-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD00635722085R0202X
GA0428772085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00340704OtherRAILROAD MEDICARE
GA000740693BOtherPEACH STATE HEALTH PLAN
GA000740693BMedicaid
GA10070880OtherAMERIGROUP
GA52670338002OtherBCBS
GAN361611OtherWELLCARE
G54520Medicare UPIN
GA30BDMZKMedicare PIN