1700851284 NPI number — MARY ALLISON HENDRICKSON-QUIRK D.O.

Table of content: MARY ALLISON HENDRICKSON-QUIRK D.O. (NPI 1700851284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700851284 NPI number — MARY ALLISON HENDRICKSON-QUIRK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON-QUIRK
Provider First Name:
MARY
Provider Middle Name:
ALLISON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDRICKSON
Provider Other First Name:
ALLISON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1700851284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1213
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31521-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-466-7188
Provider Business Mailing Address Fax Number:
912-466-7185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2415 PARKWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-466-7188
Provider Business Practice Location Address Fax Number:
912-466-7185
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: 207R00000X , with the licence number:  074434 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 074434 , 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: 115430406 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003164419A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115430404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115430405 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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