Provider Demographics
NPI:1356350425
Name:UROLOGY SPECIALISTS OF ATLANTA, LLC
Entity type:Organization
Organization Name:UROLOGY SPECIALISTS OF ATLANTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-255-3822
Mailing Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 910
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1731
Mailing Address - Country:US
Mailing Address - Phone:404-255-3822
Mailing Address - Fax:404-255-0495
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 910
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-255-3822
Practice Address - Fax:404-255-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-06
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL02-00533208800000X
208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7474OtherMEDICARE PTAN
GA=========OtherEIN
GA=========OtherEIN