1366689473 NPI number — NORTH FULTON PRIMARY CARE - WINDWARD PARKWAY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366689473 NPI number — NORTH FULTON PRIMARY CARE - WINDWARD PARKWAY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH FULTON PRIMARY CARE - WINDWARD PARKWAY, 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:
NORTH FULTON PRIMARY CARE - WINDWARD PARKWAY
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:
1366689473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741650
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:
30384-1650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-475-0888
Provider Business Mailing Address Fax Number:
770-475-3025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4895 WINDWARD PKWY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30004-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-475-0888
Provider Business Practice Location Address Fax Number:
770-475-3025
Provider Enumeration Date:
01/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
REGIONAL CFO, TENET
Authorized Official Telephone Number:
404-265-5009

Provider Taxonomy Codes

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

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

  • Identifier: 003109454A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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