Provider Demographics
NPI:1306959838
Name:AMAYA, MARC GREG
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:GREG
Last Name:AMAYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR NW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:770-874-5469
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-920-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047181207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00834237EMedicaid
GA00834237CMedicaid
GA000834237DMedicaid
GA00834237FMedicare ID - Type UnspecifiedDOUGLAS
GA93BDMFMMedicare ID - Type UnspecifiedMEDICARE KCPD
GA00834237EMedicaid