1104000660 NPI number — CLARA M PICAYO MD PROFESSIONAL CORPORATION

Table of content: (NPI 1104000660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104000660 NPI number — CLARA M PICAYO MD PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARA M PICAYO MD PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104000660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5570 BELLS FERRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACWORTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30102-2526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-926-2757
Provider Business Mailing Address Fax Number:
770-926-2758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5570 BELLS FERRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ACWORTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30102-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-926-2757
Provider Business Practice Location Address Fax Number:
770-926-2758
Provider Enumeration Date:
12/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PICAYO
Authorized Official First Name:
CLARA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN / PRESIDENT
Authorized Official Telephone Number:
770-926-2757

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  058381 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 608406833B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01149193 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com