Provider Demographics
NPI:1366621237
Name:SOUTH ATLANTA NEUROSURGERY
Entity type:Organization
Organization Name:SOUTH ATLANTA NEUROSURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REZAIAMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-997-0600
Mailing Address - Street 1:900 EAGLES LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:770-997-0600
Mailing Address - Fax:
Practice Address - Street 1:900 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:770-997-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049939174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6452Medicare PIN