1164522694 NPI number — AUDREY S ALLEYNE MD

Table of content: AUDREY S ALLEYNE MD (NPI 1164522694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164522694 NPI number — AUDREY S ALLEYNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEYNE
Provider First Name:
AUDREY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STAPLETON
Provider Other First Name:
AUDREY
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164522694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3824 HONORS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINEZ
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-9146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-267-5170
Provider Business Mailing Address Fax Number:
706-863-1148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2669 KINARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBERRY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29108-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-276-7570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2006

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: 207L00000X , with the licence number:  039479 , 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: 915210274A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G39479 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: POO135579 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 001319 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 339277 . This is a "WELLCARE CMO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 550789920 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 915210274B . This is a "GEORGIA MEDICAID AT CHILDRENS MEDICAL CENTER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 915210274B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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