1215132527 NPI number — ATHENS GYNECOLOGY PC

Table of content: (NPI 1215132527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215132527 NPI number — ATHENS GYNECOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHENS GYNECOLOGY PC
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:
EASTSIDE GYNECOLOGY
Provider Other Organization Name Type Code:
3
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:
1215132527
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1580 TREE LN
Provider Second Line Business Mailing Address:
PO BOX 325
Provider Business Mailing Address City Name:
SNELLVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30078-2207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-978-7246
Provider Business Mailing Address Fax Number:
770-979-8348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1270 PRINCE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-548-4424
Provider Business Practice Location Address Fax Number:
706-548-4880
Provider Enumeration Date:
06/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
PHYSICIAN PRESIDENT
Authorized Official Telephone Number:
706-548-4424

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000084763B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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