Provider Demographics
NPI:1285789032
Name:ATLANTA ALLERGY & OTOLARYNGOLOGY CENTER, LLC
Entity type:Organization
Organization Name:ATLANTA ALLERGY & OTOLARYNGOLOGY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-689-1100
Mailing Address - Street 1:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0034
Mailing Address - Country:US
Mailing Address - Phone:678-689-1100
Mailing Address - Fax:678-722-8206
Practice Address - Street 1:1990 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5925
Practice Address - Country:US
Practice Address - Phone:678-689-1100
Practice Address - Fax:678-722-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040364207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00681227MMedicaid
GA196754OtherBCBS PROVIDER NUMBER
GA000681227KMedicaid
GA040015437OtherMEDICARE RAILROAD ID NO
GA=========OtherTAX ID NUMBER
GAE45092Medicare UPIN
GA040015437OtherMEDICARE RAILROAD ID NO