1013961846 NPI number — PRIMARY CARE CLINICS OF GEORGIA

Table of content: (NPI 1013961846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013961846 NPI number — PRIMARY CARE CLINICS OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE CLINICS OF GEORGIA
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:
1013961846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 JESSE JEWELL PKWY SE
Provider Second Line Business Mailing Address:
SUITE 370
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501-3861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-536-1004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1240 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
SUITE 370
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-536-1004
Provider Business Practice Location Address Fax Number:
770-536-0905
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOCKER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
LEON
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-536-1004

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  041138 , 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: 158736300 . This is a "US DOL OWCP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1013961846 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 158736300 . This is a "HEALTHLINK" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00089388 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000686463B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com