1235284928 NPI number — GRENADA LAKE INPATIENT MEDICINE ASSOCIATES

Table of content: (NPI 1235284928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235284928 NPI number — GRENADA LAKE INPATIENT MEDICINE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRENADA LAKE INPATIENT MEDICINE ASSOCIATES
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:
1235284928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 52007
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:
30355-0007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-397-0060
Provider Business Mailing Address Fax Number:
678-397-0065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 J K AVENT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-227-7492
Provider Business Practice Location Address Fax Number:
662-227-7541
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEARTSILL
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
662-227-7172

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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