Provider Demographics
NPI:1194812347
Name:ATLANTA INFECTIOUS DISEASE SPECIALISTS PC
Entity type:Organization
Organization Name:ATLANTA INFECTIOUS DISEASE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-851-0081
Mailing Address - Street 1:960 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-851-0081
Mailing Address - Fax:404-851-0077
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-851-0081
Practice Address - Fax:404-851-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020679207R00000X, 207RI0200X
GA022831207R00000X, 207RI0200X
GA056179207R00000X, 207RI0200X
207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00381169C / DMedicaid
GA00381169CMedicaid
GA263262310AMedicaid
GA00265746CMedicaid
I36143Medicare UPIN
44ZCBLQMedicare ID - Type UnspecifiedSPR MCR
11BDFKFMedicare Oscar/Certification
E83160Medicare UPIN
GA00381169CMedicaid
GA00381169C / DMedicaid