1366440984 NPI number — MARK HOERMAN MD

Table of content: MARK HOERMAN MD (NPI 1366440984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366440984 NPI number — MARK HOERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOERMAN
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1366440984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30475-0407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-4986
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 EDWINA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474-8963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-538-8105
Provider Business Practice Location Address Fax Number:
912-538-8109
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  070272 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 070272 , 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: 2849327 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P55286567 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 71847 . This is a "GHI HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003138585A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2017338 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2K1057 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".




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