Provider Demographics
NPI:1487950275
Name:PEACHTREE SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:PEACHTREE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:CSA, CFA
Authorized Official - Phone:678-691-6529
Mailing Address - Street 1:7742 SPALDING DR
Mailing Address - Street 2:STE 115
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4207
Mailing Address - Country:US
Mailing Address - Phone:678-691-6529
Mailing Address - Fax:770-840-7464
Practice Address - Street 1:7742 SPALDING DR
Practice Address - Street 2:STE 115
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4207
Practice Address - Country:US
Practice Address - Phone:678-691-6529
Practice Address - Fax:770-840-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF01331246ZS0410X, 363AS0400X
IL238.000137246ZS0410X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417098229OtherPROVIDER
IL1942342761OtherPROVIDER
IL1891837696OtherPROVIDER