1801906474 NPI number — LESLIE ROSENBLATT-BROWN PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801906474 NPI number — LESLIE ROSENBLATT-BROWN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSENBLATT-BROWN
Provider First Name:
LESLIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1801906474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 HIGHWAY 54 W
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-4549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-461-3776
Provider Business Mailing Address Fax Number:
770-461-3565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 HIGHWAY 54 W
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-4549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-461-3776
Provider Business Practice Location Address Fax Number:
770-461-3565
Provider Enumeration Date:
08/30/2006

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: 363A00000X , with the licence number:  3987 , 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: 10033138 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 319981 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 451479533A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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