1366519530 NPI number — PROVIDENT HEALTH SERVICES, INC.

Table of content: (NPI 1366519530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366519530 NPI number — PROVIDENT HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENT HEALTH SERVICES, INC.
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:
6
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:
1366519530
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:
PO BOX 933213
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:
31193-1968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-350-7412
Provider Business Mailing Address Fax Number:
912-350-7297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 MALLET WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-6064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-350-7412
Provider Business Practice Location Address Fax Number:
912-350-7297
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MADDOX
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PROVIDER ENROLLMENT COORDINATOR
Authorized Official Telephone Number:
912-350-9335

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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