1063507630 NPI number — NORTHEAST GEORGIA PROCEDURE CENTER LLC

Table of content: (NPI 1063507630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063507630 NPI number — NORTHEAST GEORGIA PROCEDURE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST GEORGIA PROCEDURE CENTER 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:
1063507630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 80307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30608-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-549-8114
Provider Business Mailing Address Fax Number:
706-549-0151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 PRINCE AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-6008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-549-8114
Provider Business Practice Location Address Fax Number:
706-549-0151
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLADAY
Authorized Official First Name:
DAWNETTA
Authorized Official Middle Name:
JANENE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-549-8114

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  029-303 , 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: 938358734A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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