1912003401 NPI number — GEORGIA NEUROLOGY AND REHAB

Table of content: (NPI 1912003401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912003401 NPI number — GEORGIA NEUROLOGY AND REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA NEUROLOGY AND REHAB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COASTAL NEUROLOGICAL INSTITUTE
Provider Other Organization Name Type Code:
3
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:
1912003401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 GLYNCO PARKWAY
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-265-1357
Provider Business Mailing Address Fax Number:
912-265-0495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 GLYNCO PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-265-1357
Provider Business Practice Location Address Fax Number:
912-265-0495
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHENKMAN
Authorized Official First Name:
CARL
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
912-265-1357

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 036000 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC7432 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000516942H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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