1487810610 NPI number — MRS. TABETHA BROOME RENNER PA-AC

Table of content: MRS. TABETHA BROOME RENNER PA-AC (NPI 1487810610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487810610 NPI number — MRS. TABETHA BROOME RENNER PA-AC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENNER
Provider First Name:
TABETHA
Provider Middle Name:
BROOME
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-AC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAGIN
Provider Other First Name:
TABETHA
Provider Other Middle Name:
BROOME
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487810610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2564
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:
31203-2565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-746-5644
Provider Business Mailing Address Fax Number:
478-745-4849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 CHARTER BLVD
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:
31210-4831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-746-7577
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2008

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: 367H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367H00000X , with the licence number: 05414 , 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: 606097755D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 606097755G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 580628385 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P01101055 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 606097755E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 606097755F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 578310 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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