1992868855 NPI number — PERISSEIA PHYSICIANS, LLC

Table of content: (NPI 1992868855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992868855 NPI number — PERISSEIA PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERISSEIA PHYSICIANS, LLC
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:
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:
1992868855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1655 LEBANON RD
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30043-5128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-682-2024
Provider Business Mailing Address Fax Number:
770-682-2034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 LEBANON RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043-5128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-682-2024
Provider Business Practice Location Address Fax Number:
770-682-2034
Provider Enumeration Date:
12/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUNZ
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
770-682-2024

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  029703 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261Q00000X , with the licence number: 029703 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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