Basic Information
Provider Information | |||||||||
NPI: | 1972787760 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IANNUCCI | ||||||||
FirstName: | GLEN | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2835 BRANDYWINE RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303415510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042562593 | ||||||||
FaxNumber: | 7704889408 | ||||||||
Practice Location | |||||||||
Address1: | 3300 OLD MILTON PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300052425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042562593 | ||||||||
FaxNumber: | 7704889408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2007 | ||||||||
LastUpdateDate: | 01/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 002845 | GA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0202X | 064569 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
ID | Type | State | Issuer | Description | 002845 | 01 | GA | RESTRAINING PERMIT # | OTHER | 003100495C | 05 | GA |   | MEDICAID |