1609247311 NPI number — TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE

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 1609247311 NPI number — TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE
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:
1609247311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
719 LANIER AVE W STE A2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3695 CASCADE RD SW STE V
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30331-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-696-6595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCKOY
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
678-517-8368

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com