1053427542 NPI number — COMPREHENSIVE NEUROLOGY SPECIALIST

Table of content: (NPI 1053427542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053427542 NPI number — COMPREHENSIVE NEUROLOGY SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE NEUROLOGY SPECIALIST
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:
MARK I HARRIS MD
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 Information

NPI Number:
1053427542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 JOHNS CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-454-4685
Provider Business Mailing Address Fax Number:
770-454-4690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 JOHNS CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-6038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-454-4685
Provider Business Practice Location Address Fax Number:
770-454-4690
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
I
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
770-454-4685

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  30084 , 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: 00371115D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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