1528297140 NPI number — ISPM AT COVINGTON, LLC

Table of content: (NPI 1528297140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528297140 NPI number — ISPM AT COVINGTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISPM AT COVINGTON, 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:
Provider Other Organization Name Type Code:
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:
1528297140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11407
Provider Second Line Business Mailing Address:
DEPT 2338
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-2338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-920-4950
Provider Business Mailing Address Fax Number:
404-920-4959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5303 ADAMS STREET
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-929-9033
Provider Business Practice Location Address Fax Number:
770-929-9092
Provider Enumeration Date:
07/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BECK
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
404-920-4950

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , 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: 003127119A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1113495ASCA , issued by the state of ( GA ) . This identifiers is of the category "MEDICARE PIN".