1689088296 NPI number — MR. WILLIAM ZACHARIAH POARCH

Table of content: MR. WILLIAM ZACHARIAH POARCH (NPI 1689088296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689088296 NPI number — MR. WILLIAM ZACHARIAH POARCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POARCH
Provider First Name:
WILLIAM
Provider Middle Name:
ZACHARIAH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1689088296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 MEMORIAL DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-8662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-529-7124
Provider Business Mailing Address Fax Number:
706-529-7126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 MEMORIAL DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30720-8662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-529-7124
Provider Business Practice Location Address Fax Number:
706-529-7126
Provider Enumeration Date:
06/12/2014

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: 363LF0000X , with the licence number:  RN184431 , 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: 1042278 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003152376A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".