1922130012 NPI number — CLASSICARE MEDICAL CONSULT PC, INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922130012 NPI number — CLASSICARE MEDICAL CONSULT PC, INC

Employer Identification Number (EIN):

Provider Organization Name:

CLASSICARE MEDICAL CONSULT PC, INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

CLASSICARE INTERNAL MEDICINE

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:

1922130012

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

09/17/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

4904 TIMBER RIDGE DR STE 303

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DOUGLASVILLE

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30135-1831

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

770-489-5000

Provider Business Mailing Address Fax Number:

770-489-0305

Provider First Line Business Practice Location Address:

4904 TIMBER RIDGE DR STE 303

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DOUGLASVILLE

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30135-1831

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

770-489-5000

Provider Business Practice Location Address Fax Number:

770-489-0305

Provider Enumeration Date:

03/12/2007

Authorized Official Last Name:

YOU

Authorized Official First Name:

XIANGDONG

Authorized Official Middle Name:

Authorized Official Title or Position:

PRESIDENT

Authorized Official Telephone Number:

770-489-5000

• Taxonomy code: 207R00000X , with the licence number:  050465 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 2089568 . This is a "FIRST HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 320129 . This is a "WELLCARE OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 000934007E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 52895315 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 6104 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
• Identifier: 7676325 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 3462913 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: P00242355 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
• Identifier: 0403355 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 782253003 . This is a "GREAT-WEST" identifier . This identifiers is of the category "OTHER".
• Identifier: 21232609899 . This is a "BEECH STREET" identifier . This identifiers is of the category "OTHER".
• Identifier: 258835797 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".