1649320391 NPI number — MARGARET KENNEDY WILLIAMSON RD

Table of content: MARGARET KENNEDY WILLIAMSON RD (NPI 1649320391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649320391 NPI number — MARGARET KENNEDY WILLIAMSON RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMSON
Provider First Name:
MARGARET
Provider Middle Name:
KENNEDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENNEDY
Provider Other First Name:
MARGARET
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649320391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 TECHNOLOGY PKWY NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30165-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
762-235-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 GENTILLY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30120-8522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-490-6511
Provider Business Practice Location Address Fax Number:
770-382-5762
Provider Enumeration Date:
01/12/2007

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: 133V00000X , with the licence number:  LD002661 , 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: 977614711D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 977614711C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 977614711A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 977614711B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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