1679548168 NPI number — EVAN M BRODY DPM

Table of content: EVAN M BRODY DPM (NPI 1679548168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679548168 NPI number — EVAN M BRODY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODY
Provider First Name:
EVAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1679548168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5205 STILESBORO RD NW STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30152-7765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-310-0540
Provider Business Mailing Address Fax Number:
678-310-0538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5205 STILESBORO RD NW STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30152-7765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-310-0540
Provider Business Practice Location Address Fax Number:
678-310-0538
Provider Enumeration Date:
02/20/2006

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: 213E00000X , with the licence number:  POD000937 , 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: 581994261 . This is a "FIRST HEALTH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2700264 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 581994261 . This is a "ASSURANT HEALTH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1400101 . This is a "GHI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 457858901A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10055122 . This is a "AMERIGROUP - MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 581994261 . This is a "HUMANA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 3262431 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 6241458 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2701694 . This is a "EVERCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 332208 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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