1124002712 NPI number — CAROLYN KINZER-BEZANSON WALL M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124002712 NPI number — CAROLYN KINZER-BEZANSON WALL M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WALL

Provider First Name:

CAROLYN

Provider Middle Name:

KINZER-BEZANSON

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

KINZER-BEZANSON

Provider Other First Name:

CAROLYN

Provider Other Middle Name:

A

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

M.D.

Provider Other Last Name Type Code:

5

NPI Number:

1124002712

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/05/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 30309

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHARLESTON

Provider Business Mailing Address State Name:

SC

Provider Business Mailing Address Postal Code:

29417

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

843-554-9300

Provider Business Mailing Address Fax Number:

843-566-8780

Provider First Line Business Practice Location Address:

203 INDIGO DRIVE

Provider Second Line Business Practice Location Address:

SOUTHEASTERN PATHOLOGY ASSOCIATES, PC

Provider Business Practice Location Address City Name:

BRUNSWICK

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

31525

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

912-279-1900

Provider Business Practice Location Address Fax Number:

912-261-0753

Provider Enumeration Date:

12/06/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207ZP0102X , with the licence number:  038275 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207ZP0102X , with the licence number: ME85489 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X , with the licence number: MD29387 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X , with the licence number: MD317652 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X , with the licence number: MD.12093R/INACTIVE , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 000931356F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000931356I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 015391500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".