Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 42182 | GA |
NPI | 1366441941 |
---|---|
Provider Name | John Bleacher |
First Address | Atlanta, GA 30342-2807 |
Second Address | Atlanta, GA 30342-2807 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2005 |
Last Update Date | 25/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H08170 | (02) | GA |