1700944568 NPI number — DIANE BARDINA KORZENIEWSKI

Table of content: DIANE BARDINA KORZENIEWSKI (NPI 1700944568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700944568 NPI number — DIANE BARDINA KORZENIEWSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORZENIEWSKI
Provider First Name:
DIANE
Provider Middle Name:
BARDINA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1700944568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1813 WATUGA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501-1549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-287-1689
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 OLD NORCROSS RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-3389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-377-2833
Provider Business Practice Location Address Fax Number:
678-377-2882
Provider Enumeration Date:
12/05/2006

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: 225XP0200X , with the licence number:  OT003986 , 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: 183063315A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340243 . This is a "WELLCARE-AAKTS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10037631 . This is a "AMERIGROUP-AAKTS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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