1962838391 NPI number — WILLIAM J SUMMERFORD PA-AA

Table of content: WILLIAM J SUMMERFORD PA-AA (NPI 1962838391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962838391 NPI number — WILLIAM J SUMMERFORD PA-AA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMMERFORD
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-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:
1962838391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 551420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33355-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
855-851-4405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HEMLOCK ST
Provider Second Line Business Practice Location Address:
MSC10
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-507-5244
Provider Business Practice Location Address Fax Number:
855-851-4405
Provider Enumeration Date:
09/17/2013

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:  006961 , 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: 006961 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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