1306858121 NPI number — MEDSIDE CORPORATION

Table of content: (NPI 1306858121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306858121 NPI number — MEDSIDE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSIDE CORPORATION
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:
MEDSIDE HEALTHCARE
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:
1306858121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 HOPE RD # 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30350-2957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-633-7433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 HOPE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDY SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-633-7433
Provider Business Practice Location Address Fax Number:
888-633-7430
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAYSMAN
Authorized Official First Name:
VIKTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
404-633-7433

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  060-245-H , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251E00000X , with the licence number: 060-R-0068 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: 060-R-0068 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003231615A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00869943D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00869943B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00869943A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00849527A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00869943C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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