1053505743 NPI number — DR. SALLY S AGERSBORG M.D., PH.D.

Table of content: DR. SALLY S AGERSBORG M.D., PH.D. (NPI 1053505743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053505743 NPI number — DR. SALLY S AGERSBORG M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGERSBORG
Provider First Name:
SALLY
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053505743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 947365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30394-7365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 TECHNOLOGY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618-2478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-540-9421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZH0000X , with the licence number:  35178 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: 25MA09454000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: 263526 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: 36038 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: MD61433822 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: ME103427 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: N1972 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: MD432959 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X , with the licence number: A82499 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZH0000X , with the licence number: D0066759 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)