Basic Information
| Provider Information | |||||||||
| NPI: | 1811175326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROOT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647070 | ||||||||
| FaxNumber: | 2547787197 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | KAISER PERMANENTE GLENLAKE MEDICAL CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542982682 | ||||||||
| FaxNumber: | 2547787197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | P0124 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | A95787 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 070902 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 11952742 | 01 | CA | CAQH PROVIDER ID | OTHER |