Provider Demographics
NPI:1104875012
Name:TAPP, WILLIE W IV (MD)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:W
Last Name:TAPP
Suffix:IV
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 1:2727 PACES FERRY RD SE STE 1-1100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6151
Mailing Address - Country:US
Mailing Address - Phone:470-271-3418
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051746207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00962024AMedicaid
GA00962024AMedicaid
GAH62335Medicare UPIN