1508977299 NPI number — DR. JAZA MONIQUE MARINA MD

Table of content: HEATHER DENISE MILLER (NPI 1184260424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508977299 NPI number — DR. JAZA MONIQUE MARINA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARINA
Provider First Name:
JAZA
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARINA
Provider Other First Name:
JAZA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508977299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT RD, NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 CUMBERLAND PARKWAY
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE CUMBERLAND MEDICAL CENTER
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-431-4107
Provider Business Practice Location Address Fax Number:
770-431-4373
Provider Enumeration Date:
08/31/2006

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: 207R00000X , with the licence number:  055267 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 055267 , 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: 387570 . This is a "BCBS - EAMC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 783527 . This is a "BCBS - BCPHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 389254619C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 389254619A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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