1134334832 NPI number — POWDER SPRINGS MEDICAL CLINIC, INC.

Table of content: (NPI 1134334832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134334832 NPI number — POWDER SPRINGS MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWDER SPRINGS MEDICAL CLINIC, INC.
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:
1134334832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4045B LINDLEY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POWDER SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30127-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-943-1636
Provider Business Mailing Address Fax Number:
770-943-7941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4045-B LINDLEY CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWDER SOPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-943-1636
Provider Business Practice Location Address Fax Number:
770-943-7941
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-943-1636

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  019698 , 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: 0100673 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10041190 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4569669 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00256198 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 3661647 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52143080 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 314139 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GRP3770 . This is a "MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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