1720274301 NPI number — RANDALL W KRIZAN AA

Table of content: RANDALL W KRIZAN AA (NPI 1720274301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720274301 NPI number — RANDALL W KRIZAN AA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRIZAN
Provider First Name:
RANDALL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AA
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:
1720274301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 26TH ST NW
Provider Second Line Business Mailing Address:
APT 2203
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1365 CLIFTON RD NE
Provider Second Line Business Practice Location Address:
SUITE BT209
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30322-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-778-4040
Provider Business Practice Location Address Fax Number:
404-778-5059
Provider Enumeration Date:
09/18/2007

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: 367H00000X , with the licence number:  005149 , 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: 222812602A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".