1598193831 NPI number — GRAHAM REAVES MSOT

Table of content: GRAHAM REAVES MSOT (NPI 1598193831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598193831 NPI number — GRAHAM REAVES MSOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REAVES
Provider First Name:
GRAHAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOT
Provider Gender Code:
M

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:
1598193831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 PEACHTREE VALLEY RD NE
Provider Second Line Business Mailing Address:
APARTMENT 1727
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-676-2413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 PHOENIX BLVD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30349-5063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-355-0743
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2013

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: 273Y00000X , with the licence number:  005790 , 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)