Provider Demographics
NPI:1720011489
Name:CLASSIC CITY CARDIOLOGY
Entity type:Organization
Organization Name:CLASSIC CITY CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-543-8444
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 300 B
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2179
Mailing Address - Country:US
Mailing Address - Phone:706-543-8444
Mailing Address - Fax:706-543-5656
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 300 B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-543-8444
Practice Address - Fax:706-543-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038831207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Not Answered207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA731865OtherBLUE CROSS/ BLUE SHIELD
60051487OtherRAILROAD MEDICARE
GA731865OtherBLUE CROSS/ BLUE SHIELD