Provider Demographics
NPI:1396742532
Name:AMERISOUTH MOBILITY, LLC
Entity type:Organization
Organization Name:AMERISOUTH MOBILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DANNENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-321-5500
Mailing Address - Street 1:26 EXECUTIVE PARK W
Mailing Address - Street 2:SUITE 2603
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2202
Mailing Address - Country:US
Mailing Address - Phone:404-321-5500
Mailing Address - Fax:404-321-5530
Practice Address - Street 1:26 EXECUTIVE PARK W
Practice Address - Street 2:SUITE 2603
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2202
Practice Address - Country:US
Practice Address - Phone:404-321-5500
Practice Address - Fax:404-321-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAK931128332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00849142AMedicaid
GA00849142AMedicaid