1447340872 NPI number — STAT SURGICAL SERVICES OF MACON, LLC

Table of content: (NPI 1447340872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447340872 NPI number — STAT SURGICAL SERVICES OF MACON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAT SURGICAL SERVICES OF MACON, 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:
STAT SURGICAL SERVICES OF MACON
Provider Other Organization Name Type Code:
4
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:
1447340872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
827 PITTS CHAPEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31217-2327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-986-6825
Provider Business Mailing Address Fax Number:
478-986-6825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 PITTS CHAPEL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31217-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-986-6825
Provider Business Practice Location Address Fax Number:
478-986-6825
Provider Enumeration Date:
10/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHESTER
Authorized Official First Name:
JUNE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
478-986-6825

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , with the licence number:  RN039858 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WR0006X , with the licence number: RN047391 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 600951600 . This is a "US DEPARTMENT OF TREASURY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52207252 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52268332 . 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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