Provider Demographics
NPI:1104088905
Name:PIEDMONT PROFESSIONAL SERVICES, LLC
Entity type:Organization
Organization Name:PIEDMONT PROFESSIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-271-3427
Mailing Address - Street 1:PO BOX 102038
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1855 HUDSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5000
Practice Address - Country:US
Practice Address - Phone:770-801-2500
Practice Address - Fax:770-803-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA207RC0000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty