1326040114 NPI number — DPM BRISSETT NRGA LLC

Table of content: (NPI 1326040114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326040114 NPI number — DPM BRISSETT NRGA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DPM BRISSETT NRGA 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:
1326040114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5124 GROVE FIELD PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30038-2387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-721-2072
Provider Business Mailing Address Fax Number:
866-678-9749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5124 GROVE FIELD PT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30038-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-721-2072
Provider Business Practice Location Address Fax Number:
866-678-9749
Provider Enumeration Date:
08/11/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRISSETT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DPM
Authorized Official Telephone Number:
646-721-2072

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  POD000950 , 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: 48SCIQW . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".