1528308319 NPI number — SUSAN GROGAN SEMMES CPO/LPO

Table of content: SUSAN GROGAN SEMMES CPO/LPO (NPI 1528308319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528308319 NPI number — SUSAN GROGAN SEMMES CPO/LPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEMMES
Provider First Name:
SUSAN
Provider Middle Name:
GROGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPO/LPO
Provider Gender Code:
F

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:
1528308319
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 NORTHSIDE DR
Provider Second Line Business Mailing Address:
STE D
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31602-1866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-245-8009
Provider Business Mailing Address Fax Number:
229-247-2090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 NORTHSIDE DR
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-1866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-245-8009
Provider Business Practice Location Address Fax Number:
229-247-2090
Provider Enumeration Date:
02/15/2013

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: 222Z00000X , with the licence number:  GA 000004 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: GA 000004 , 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: 000690852A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C15505 . This is a "BOC CPO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: LPO 000004 . This is a "GEORGIA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: CPO02244 . This is a "ABC CPO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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