1275769135 NPI number — STACY D. DOUGHERTY-WELCH M.D.

Table of content: STACY D. DOUGHERTY-WELCH M.D. (NPI 1275769135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275769135 NPI number — STACY D. DOUGHERTY-WELCH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY-WELCH
Provider First Name:
STACY
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUGHERTY-WELCH
Provider Other First Name:
STACY
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275769135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 BOULEVARD NE, STE 500
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:
30312-1212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-265-3635
Provider Business Mailing Address Fax Number:
404-265-3634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 BOULEVARD NE
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30312-1212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-265-3635
Provider Business Practice Location Address Fax Number:
404-265-3634
Provider Enumeration Date:
06/05/2009

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: 208600000X , with the licence number:  157387 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 69797 , 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)