Provider Demographics
NPI:1699778563
Name:HEMOPHILIA OF GEORGIA
Entity type:Organization
Organization Name:HEMOPHILIA OF GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-518-8272
Mailing Address - Street 1:8607 ROBERTS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2237
Mailing Address - Country:US
Mailing Address - Phone:770-518-8272
Mailing Address - Fax:770-518-3310
Practice Address - Street 1:8607 ROBERTS DR STE 150
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-2237
Practice Address - Country:US
Practice Address - Phone:770-518-8272
Practice Address - Fax:770-518-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0074803336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018678OtherPK
GA00528393AMedicaid
555413545SMedicare PIN