Basic Information
Provider Information | |||||||||
NPI: | 1275731580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAILEY | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 742616 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303742616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702198420 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 852 DACULA RD | ||||||||
Address2: |   | ||||||||
City: | DACULA | ||||||||
State: | GA | ||||||||
PostalCode: | 300193185 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708489380 | ||||||||
FaxNumber: | 7708489381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2007 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LL 30124 | SC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 62809 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 189684661A | 05 | GA |   | MEDICAID | 189684661C | 05 | GA |   | MEDICAID |