1437149978 NPI number — MORRIS MICHAEL PULLIAM M.D.

Table of content: MORRIS MICHAEL PULLIAM M.D. (NPI 1437149978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437149978 NPI number — MORRIS MICHAEL PULLIAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PULLIAM
Provider First Name:
MORRIS
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1437149978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30015-0469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-786-9312
Provider Business Mailing Address Fax Number:
770-784-9603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4165 HOSPITAL DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-786-9312
Provider Business Practice Location Address Fax Number:
770-784-9603
Provider Enumeration Date:
10/26/2005

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: 207W00000X , with the licence number:  11036 , 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: 5809692830000E . This is a "ALL OTHER CARRIERS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 451376 . This is a "STATE MERIT SYSTEM" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 067332 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000012229D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 406180004 . This is a "RRR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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