1588825277 NPI number — SIERRA MEDICAL SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588825277 NPI number — SIERRA MEDICAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIERRA MEDICAL SERVICES, 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:
1588825277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 28170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31221-8170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-254-5943
Provider Business Mailing Address Fax Number:
478-254-6093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
528 SOUTH 8TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRIFFIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-467-1224
Provider Business Practice Location Address Fax Number:
770-467-1225
Provider Enumeration Date:
06/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DE LASIERRA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-610-8620

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  056820 , 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: 382655211F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DP1571 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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