Basic Information
| Provider Information | |||||||||
| NPI: | 1932477429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT ED PROFESSIONALS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116750 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009263303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2011 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | AQUINO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 11090929 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003123631A | 05 | GA | MEDICAID |