Provider Demographics
NPI:1285265546
Name:IDEA BODY INSTITUTE ATLANTA ASC
Entity type:Organization
Organization Name:IDEA BODY INSTITUTE ATLANTA ASC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-466-6760
Mailing Address - Street 1:371 E PACES FERRY RD NE STE 450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3292
Mailing Address - Country:US
Mailing Address - Phone:678-466-6760
Mailing Address - Fax:
Practice Address - Street 1:371 E PACES FERRY RD NE STE 450
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3292
Practice Address - Country:US
Practice Address - Phone:678-466-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA SURGICARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1992981302Medicaid
GA1558539155Medicaid