1285937060 NPI number — GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.

Table of content: (NPI 1285937060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285937060 NPI number — GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.
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:
1285937060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 RICKARD RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62704-1017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-787-9540
Provider Business Mailing Address Fax Number:
217-787-9183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 BEDFORD DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-1987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-622-8114
Provider Business Practice Location Address Fax Number:
321-622-4649
Provider Enumeration Date:
12/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MERTZ
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
217-787-9540

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  0036078693 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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