Provider Demographics
NPI:1730334582
Name:EAR NOSE AND THROAT FACIAL PLASTICS PC
Entity type:Organization
Organization Name:EAR NOSE AND THROAT FACIAL PLASTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOOKER
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:404-350-9200
Mailing Address - Street 1:550 PEACHTREE ST NE
Mailing Address - Street 2:SUITE 1075
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2247
Mailing Address - Country:US
Mailing Address - Phone:404-350-9200
Mailing Address - Fax:404-529-9092
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:SUITE 1075
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-350-9200
Practice Address - Fax:404-529-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039935174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000663891AMedicaid
GA04BDBQMMedicare UPIN