1578773750 NPI number — JIMMY L. GREGORY DPM, INC

Table of content: (NPI 1578773750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578773750 NPI number — JIMMY L. GREGORY DPM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIMMY L. GREGORY DPM, INC
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:
1578773750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2140 CALVERTON LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30331-2235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-202-8916
Provider Business Mailing Address Fax Number:
404-284-8006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3546 COVINGTON HWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30032-1823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-284-7744
Provider Business Practice Location Address Fax Number:
404-284-8006
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOVE
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
404-284-7744

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  000598 , 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: GRP6110 . This is a "MEDICARE PART B" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: DC7572 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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