1598857229 NPI number — LEEWAY MEDICAL GROUP, P.C.

Table of content: (NPI 1346832193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598857229 NPI number — LEEWAY MEDICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEEWAY MEDICAL GROUP, P.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:
1598857229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1665 WATERWAY XING SW
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:
30331-8060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-577-6121
Provider Business Mailing Address Fax Number:
770-577-1152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8311 OFFICE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-6935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-577-6121
Provider Business Practice Location Address Fax Number:
770-577-1152
Provider Enumeration Date:
09/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEE III MD
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-577-6121

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CH8739 . This is a "MCRR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0400158 . This is a "EVERCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52255410 001 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".