Provider Demographics
NPI:1699895961
Name:PROVIDENCE HEALTHCARE
Entity type:Organization
Organization Name:PROVIDENCE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-676-6000
Mailing Address - Street 1:4646 N SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6304
Mailing Address - Country:US
Mailing Address - Phone:770-676-6000
Mailing Address - Fax:770-392-9805
Practice Address - Street 1:4646 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6304
Practice Address - Country:US
Practice Address - Phone:770-676-6000
Practice Address - Fax:770-392-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005530111N00000X
FL000186171100000X
GA207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50014615OtherTAT
GA826713OtherBLUECROSS BLUE SHIELD
GAD44849OtherUPIN