1265558118 NPI number — GEORGIA SOUTHERN UNIVERSITY

Table of content: (NPI 1265558118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265558118 NPI number — GEORGIA SOUTHERN UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA SOUTHERN UNIVERSITY
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:
GEORGIA SOUTHERN UNIVERSITY HEALTH SERVICES
Provider Other Organization Name Type Code:
3
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:
1265558118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79608-5199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-890-6390
Provider Business Mailing Address Fax Number:
325-437-8390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
984 PLANT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30460-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-478-5641
Provider Business Practice Location Address Fax Number:
912-478-1893
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORRIS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HEALTH SERVICES
Authorized Official Telephone Number:
912-478-5641

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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