1073623666 NPI number — PAMELA ELENE GJERDE PT

Table of content: PAMELA ELENE GJERDE PT (NPI 1073623666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073623666 NPI number — PAMELA ELENE GJERDE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GJERDE
Provider First Name:
PAMELA
Provider Middle Name:
ELENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1073623666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6308 DRUID HILLS RESERVE DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30329-2056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-371-3688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 EXECUTIVE PARK SOUTH NE
Provider Second Line Business Practice Location Address:
STE 190
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30329-2288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-778-6390
Provider Business Practice Location Address Fax Number:
404-778-6340
Provider Enumeration Date:
08/30/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT008073 . This is a "LICENSE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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