Basic Information
| Provider Information | |||||||||
| NPI: | 1194725085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | THERMUTUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 PIEDMONT AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303032544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047565764 | ||||||||
| FaxNumber: | 4047565252 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST | ||||||||
| Address2: | STE 1615 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045778180 | ||||||||
| FaxNumber: | 4045774761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 19552 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00162313A | 05 | GA | MEDICAID |