1366499634 NPI number — MARIXIE Q LEONOR-GILRANE MD

Table of content: MARIXIE Q LEONOR-GILRANE MD (NPI 1366499634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366499634 NPI number — MARIXIE Q LEONOR-GILRANE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEONOR-GILRANE
Provider First Name:
MARIXIE
Provider Middle Name:
Q
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILRANE
Provider Other First Name:
MARIXIE
Provider Other Middle Name:
Q
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366499634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
239 VILLAGE CENTER PKWY
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-9024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-506-0095
Provider Business Mailing Address Fax Number:
770-506-8060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 VILLAGE CENTER PKWY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-9024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-506-0095
Provider Business Practice Location Address Fax Number:
770-506-8060
Provider Enumeration Date:
05/30/2006

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: 208000000X , with the licence number:  023757 , 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: 0971235 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 582262190 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 582262190 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 582262190 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576122D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52480810 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6051 . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10033072 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 582262190 . This is a "HUMANA TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6051 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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