1972603785 NPI number — DR. ANASTASIOS L GEORGIOU M.D.

Table of content: DR. ANASTASIOS L GEORGIOU M.D. (NPI 1972603785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972603785 NPI number — DR. ANASTASIOS L GEORGIOU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEORGIOU
Provider First Name:
ANASTASIOS
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1972603785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 HIGHWAY 45 BYP
Provider Second Line Business Mailing Address:
SUITE 607
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305-4436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-668-5335
Provider Business Mailing Address Fax Number:
731-668-6670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 SKYLINE DR
Provider Second Line Business Practice Location Address:
RADIATION ONCOLOGY DEPT
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38301-3923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-541-6250
Provider Business Practice Location Address Fax Number:
731-541-6858
Provider Enumeration Date:
09/22/2006

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: 2085R0001X , with the licence number:  MD024422 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3073988 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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