1568670180 NPI number — ROSENTHAL, CLARK AND MATSURRA

Table of content: (NPI 1568670180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568670180 NPI number — ROSENTHAL, CLARK AND MATSURRA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSENTHAL, CLARK AND MATSURRA
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:
ATLANTA VASCULAR SPECIALISTS
Provider Other Organization Name Type Code:
5
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:
1568670180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 BOULEVARD NE
Provider Second Line Business Mailing Address:
N.E. 412
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30312-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-524-0095
Provider Business Mailing Address Fax Number:
404-658-9558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 BOULEVARD
Provider Second Line Business Practice Location Address:
N.E. 412
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30312-1264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-524-0095
Provider Business Practice Location Address Fax Number:
404-658-9558
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DILLARD
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
404-524-0095

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 055001472A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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