1174905830 NPI number — FIDELITY HEALTH CARE GROUP, LLC

Table of content: (NPI 1174905830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174905830 NPI number — FIDELITY HEALTH CARE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIDELITY HEALTH CARE GROUP, 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:
1174905830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 EAGLES LANDING PKWY
Provider Second Line Business Mailing Address:
# 152
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-7343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-929-8967
Provider Business Mailing Address Fax Number:
404-601-8328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 EAGLES LANDING PKWY
Provider Second Line Business Practice Location Address:
# 152
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-7343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-929-8967
Provider Business Practice Location Address Fax Number:
404-601-8328
Provider Enumeration Date:
06/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GLENN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
478-290-8509

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  038495 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 038495 , 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: 1194765420 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 106322600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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