1578955795 NPI number — PHYSICIAN'S EXPRESS CARE AT CREEKSTONE

Table of content: (NPI 1578955795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578955795 NPI number — PHYSICIAN'S EXPRESS CARE AT CREEKSTONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN'S EXPRESS CARE AT CREEKSTONE
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:
6
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:
1578955795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1780 PEACHTREE PKWY STE 3302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30041-6834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-772-1830
Provider Business Mailing Address Fax Number:
470-239-7296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1780 PEACHTREE PKWY STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-6834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-772-1830
Provider Business Practice Location Address Fax Number:
470-239-7296
Provider Enumeration Date:
02/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DUKES
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-772-1830

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  51875 , 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)





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