1063512523 NPI number — JENNIE L. HODGES PA

Table of content: MRS. ELIZABETH A MCPHERSON CRNA (NPI 1245273721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063512523 NPI number — JENNIE L. HODGES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODGES
Provider First Name:
JENNIE
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PILL
Provider Other First Name:
JENNIE
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063512523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1499 WALTON WAY
Provider Second Line Business Mailing Address:
STE 1400
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30901-2650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-724-6100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30912-0004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-721-2542
Provider Business Practice Location Address Fax Number:
706-721-6676
Provider Enumeration Date:
09/25/2006

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: 363AM0700X , with the licence number:  001865 , 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: 0148PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100002064A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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