1396735833 NPI number — NEWTON ROCKDALE AMBULATORY SURGERY CENTER

Table of content: (NPI 1396735833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396735833 NPI number — NEWTON ROCKDALE AMBULATORY SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWTON ROCKDALE AMBULATORY SURGERY CENTER
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:
PULLIAM AMBULATORY SURGERY CENTER
Provider Other Organization Name Type Code:
5
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:
1396735833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30015-0469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-786-1234
Provider Business Mailing Address Fax Number:
770-385-0813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4167 HOSPITAL DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-786-1234
Provider Business Practice Location Address Fax Number:
770-385-0813
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PULLIAM
Authorized Official First Name:
MORRIS
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-786-1234

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  122-036 , 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: 000420802A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490002755 . This is a "RRR MEDICARE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 51001066001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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