1. Home
  2. Directory
  3. Georgia
  4. Austell
  5. Internal Medicine
  6. NPI Profile
  7. NPI Record 1639396518

GEORGE T DERISO III M.D.
Complete NPI Record 1639396518
Internal Medicine - Cardiovascular Disease in Austell, GA


Quality Rating: 93.03 out of 100 score

NPI Status: Active since April 20, 2007

Contact Information

1700 HOSPITAL SOUTH DR
SUITE 409
AUSTELL, GA
ZIP 30106
Phone: (770) 424-6893
Fax: (770) 528-9938

Get Directions

Table of Contents

  1. NPI
  2. Entity Type Code
  3. Provider Last Name Legal Name
  4. Provider First Name
  5. Provider Middle Name
  6. Provider Name Suffix Text
  7. Provider Credential Text
  8. Provider First Line Business Mailing Address
  9. Provider Second Line Business Mailing Address
  10. Provider Business Mailing Address City Name
  11. Provider Business Mailing Address State Name
  12. Provider Business Mailing Address Postal Code
  13. Provider Business Mailing Address Country Code If outside U S
  14. Provider First Line Business Practice Location Address
  15. Provider Second Line Business Practice Location Address
  16. Provider Business Practice Location Address City Name
  17. Provider Business Practice Location Address State Name
  18. Provider Business Practice Location Address Postal Code
  19. Provider Business Practice Location Address Country Code If outside U S
  20. Provider Business Practice Location Address Telephone Number
  21. Provider Business Practice Location Address Fax Number
  22. Provider Enumeration Date
  23. Last Update Date
  24. Provider Gender Code
  25. Healthcare Provider Taxonomy Code 1
  26. Provider License Number 1
  27. Provider License Number State Code 1
  28. Healthcare Provider Primary Taxonomy Switch 1
  29. Other Provider Identifier 1
  30. Other Provider Identifier Type Code 1
  31. Other Provider Identifier State 1
  32. Other Provider Identifier 2
  33. Other Provider Identifier Type Code 2
  34. Other Provider Identifier State 2
  35. Other Provider Identifier 3
  36. Other Provider Identifier Type Code 3
  37. Other Provider Identifier State 3
  38. Other Provider Identifier 4
  39. Other Provider Identifier Type Code 4
  40. Other Provider Identifier State 4
  41. Is Sole Proprietor

Complete NPI Dataset

This page represents the complete record for NPI 1639396518. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1639396518
The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
Entity Type Code: 1
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Provider First Name: GEORGE
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Middle Name: T
The city name in the location address of the provider being identified.
Provider Name Suffix Text: III
The State code in the location of the provider being identified.
Provider Credential Text: M.D.
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider First Line Business Mailing Address: 805 SANDY PLAINS ROAD
The country code in the location address of the provider being identified.
Provider Second Line Business Mailing Address: MEDICAL STAFF SERVICES
The telephone number associated with the location address of the provider being identified.
Provider Business Mailing Address City Name: MARIETTA
The fax number associated with the location address of the provider being identified.
Provider Business Mailing Address State Name: GA
The date the provider was assigned a unique identifier (assigned an NPI).
Provider Business Mailing Address Postal Code: 300666340
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Country Code If outside U S : US
The code designating the provider's gender if the provider is a person.
Provider First Line Business Practice Location Address: 1700 HOSPITAL SOUTH DR
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location Address: SUITE 409
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: AUSTELL
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: GA
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 301066810
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 7704246893
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 7705289938
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 4/20/2007
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 10/29/2019
The date that a record was last updated or changed.
Provider Gender Code: M
The code designating the provider's gender if the provider is a person.
Healthcare Provider Taxonomy Code 1: 207RC0000X
This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: 047732
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
Provider License Number State Code 1: GA
The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
Healthcare Provider Primary Taxonomy Switch 1: Y
This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Other Provider Identifier 1: 000904208T
An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 1: 05
A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 1: GA
The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 2: 000904208V
An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 2: 05
A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 2: GA
The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 3: 000904208S
An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 3: 05
A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 3: GA
The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 4: 000904208W
An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 4: 05
A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 4: GA
The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Is Sole Proprietor: N
Indicates whether the provider is registered as a sole proprietor. This is a single-character code: "Y" means the provider operates as a sole proprietor, and "N" means they do not.