Provider Demographics
NPI:1962740001
Name:CHESHIRE BRIDGE GYN
Entity type:Organization
Organization Name:CHESHIRE BRIDGE GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-892-3239
Mailing Address - Street 1:1874 PIEDMONT RD NE
Mailing Address - Street 2:SUITE 580 E
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4869
Mailing Address - Country:US
Mailing Address - Phone:404-602-4495
Mailing Address - Fax:404-607-0728
Practice Address - Street 1:1874 PIEDMONT RD NE
Practice Address - Street 2:SUITE 580 E
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-4869
Practice Address - Country:US
Practice Address - Phone:404-602-4495
Practice Address - Fax:404-607-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23086261Q00000X, 261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16BBCPCMedicare UPIN