1205102282 NPI number — ATLANTA PELVIC & ORTHOPEDIC REHAB CENTER, LLC

Table of content: DR. LISA RUBIN KORNBLAU D.D.S.,M.S (NPI 1164732905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205102282 NPI number — ATLANTA PELVIC & ORTHOPEDIC REHAB CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA PELVIC & ORTHOPEDIC REHAB CENTER, 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:
1205102282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2591 PIEDMONT RD NE STE 104
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:
30324-6281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-935-9000
Provider Business Mailing Address Fax Number:
404-935-9009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2591 PIEDMONT RD NE STE 104
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:
30324-6281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-935-9000
Provider Business Practice Location Address Fax Number:
404-935-9009
Provider Enumeration Date:
03/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
OLABISI
Authorized Official Middle Name:
JARRETT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-935-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT007193 , 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)





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