1851358337 NPI number — EVAN N LANDIS MD

Table of content: EVAN N LANDIS MD (NPI 1851358337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851358337 NPI number — EVAN N LANDIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
EVAN
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANDIS
Provider Other First Name:
EVAN
Provider Other Middle Name:
NEIL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1851358337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400C OLD MILTON PKWY
Provider Second Line Business Mailing Address:
STE 545
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-751-0800
Provider Business Mailing Address Fax Number:
770-751-7198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400C OLD MILTON PKWY
Provider Second Line Business Practice Location Address:
STE 545
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-751-0800
Provider Business Practice Location Address Fax Number:
770-751-7198
Provider Enumeration Date:
04/27/2006

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: 208000000X , with the licence number:  024010 , 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)