1083032254 NPI number — PIEDMONT EXPRESS CARE AT SUTTON ROAD, LLC

Table of content: (NPI 1083032254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083032254 NPI number — PIEDMONT EXPRESS CARE AT SUTTON ROAD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIEDMONT EXPRESS CARE AT SUTTON ROAD, 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:
SUTTON ROAD PEDIATRICS
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:
1083032254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743012
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:
30374-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-547-8181
Provider Business Mailing Address Fax Number:
803-547-8180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 RIVERCROSSING DR
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29715-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-547-8181
Provider Business Practice Location Address Fax Number:
803-547-8180
Provider Enumeration Date:
04/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
REGIONAL CFO, TENET
Authorized Official Telephone Number:
404-265-5009

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com