1477858736 NPI number — GEORGIA PRO-HEALTH PARTNERS 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 1477858736 NPI number — GEORGIA PRO-HEALTH PARTNERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PRO-HEALTH PARTNERS 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:
SOUTH COBB PAIN MANAGEMENT
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:
1477858736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30023-5700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-432-0234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3065 S COBB DR SE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-432-1164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KOHOUT
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
404-432-0234

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)





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