Basic Information
Provider Information | |||||||||
NPI: | 1417912395 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MURPHY | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1838 AMERICAN WAY | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300436611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709957622 | ||||||||
FaxNumber: | 7709957854 | ||||||||
Practice Location | |||||||||
Address1: | 5665 PEACHTREE DUNWOODY RD NE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303421764 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042526104 | ||||||||
FaxNumber: | 4042571808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2006 | ||||||||
LastUpdateDate: | 03/27/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 024995 | GA | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 237690 | 01 | GA | BCBS EDI# | OTHER | 000266648E | 05 | GA |   | MEDICAID | 000266648C | 05 | GA |   | MEDICAID | 00266648B | 05 | GA |   | MEDICAID | 330002019 | 01 | GA | RR MEDICARE | OTHER |