1407843642 NPI number — TERESA PIRTLE GORDY CRNA

Table of content: TERESA PIRTLE GORDY CRNA (NPI 1407843642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407843642 NPI number — TERESA PIRTLE GORDY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDY
Provider First Name:
TERESA
Provider Middle Name:
PIRTLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORDY
Provider Other First Name:
TERESA
Provider Other Middle Name:
LINN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1407843642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3532 STEVENS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINEZ
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-8901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-228-5491
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
AIKEN REGIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29801-6302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-641-5489
Provider Business Practice Location Address Fax Number:
803-641-5148
Provider Enumeration Date:
10/03/2005

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: 367500000X , with the licence number:  R94915 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AN1302 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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