1083603609 NPI number — SUMMERHILL, LLC

Table of content: (NPI 1083603609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083603609 NPI number — SUMMERHILL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERHILL, 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:
1083603609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 MACON RD
Provider Second Line Business Mailing Address:
STE D
Provider Business Mailing Address City Name:
PERRY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31069-2679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-988-1294
Provider Business Mailing Address Fax Number:
478-988-1193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 STANLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31069-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-987-3100
Provider Business Practice Location Address Fax Number:
478-987-0664
Provider Enumeration Date:
10/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
478-988-1294

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-076-1106 , 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: 000142139B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000142139A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".