Basic Information
| Provider Information | |||||||||
| NPI: | 1366671711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOODALTER | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046864411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046864411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | 83281 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207R00000X | 83281 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 83281 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.