1689431207 NPI number — GEORGIA PHYSICIAN ASSOCIATGES PC

Table of content: GRETCHEN STADNIK GRUNDON M.A., BCBA (NPI 1346581063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689431207 NPI number — GEORGIA PHYSICIAN ASSOCIATGES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PHYSICIAN ASSOCIATGES PC
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:
1689431207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 VILLAGE PROFESSIONAL DRIVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-8499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-661-4545
Provider Business Mailing Address Fax Number:
678-265-4299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1247 TUSCANY DRIVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BRASELTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30517-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-661-4545
Provider Business Practice Location Address Fax Number:
678-265-4299
Provider Enumeration Date:
02/29/2024

Additional Information

Authorized Official

Authorized Official Last Name:
BEECHAM
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
678-661-4545

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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