1285789032 NPI number — ATLANTA ALLERGY & OTOLARYNGOLOGY CENTER, LLC

Table of content: (NPI 1285789032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285789032 NPI number — ATLANTA ALLERGY & OTOLARYNGOLOGY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA ALLERGY & OTOLARYNGOLOGY CENTER, LLC
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:
SLEEP AND SINUS CENTERS OF GEORGIA
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:
1285789032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-0034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-689-1100
Provider Business Mailing Address Fax Number:
678-722-8206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1990 RIVERSIDE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-689-1100
Provider Business Practice Location Address Fax Number:
678-722-8206
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DILLARD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-689-1100

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  040364 , 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: 00681227M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196754 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000681227K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040015437 . This is a "MEDICARE RAILROAD ID NO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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