1164962882 NPI number — IPSUM DIAGNOSTICS LLC

Table of content: (NPI 1164962882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164962882 NPI number — IPSUM DIAGNOSTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IPSUM DIAGNOSTICS 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:
1164962882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8607 ROBERTS DR STE 250
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:
30350-2237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-915-2299
Provider Business Mailing Address Fax Number:
833-964-0184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8607 ROBERTS DR STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30350-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-915-2299
Provider Business Practice Location Address Fax Number:
833-964-0184
Provider Enumeration Date:
02/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
COLIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
404-441-8180

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  11D2125186 , 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: 397268901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060-403 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 45D2299234 . This is a "CLIA NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 003198560A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101233400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com