Provider Demographics
NPI:1609612373
Name:UNITED HEALTHCARE SYSTEM OF GEORGIA INC.
Entity type:Organization
Organization Name:UNITED HEALTHCARE SYSTEM OF GEORGIA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-884-2742
Mailing Address - Street 1:777 CLEVELAND AVE SW STE 500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW STE 500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7115
Practice Address - Country:US
Practice Address - Phone:404-755-2291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1285654301Medicaid