1093716979 NPI number — DEKALB MEDICAL CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093716979 NPI number — DEKALB MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB MEDICAL CENTER, INC.
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:
6
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:
1093716979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 N DECATUR RD STE 1003B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-5918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-501-5025
Provider Business Mailing Address Fax Number:
404-501-5627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2701 N DECATUR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-501-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
URBISTONDO
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
404-501-5025

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  044039 , 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: 000000536A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100047 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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