1699778563 NPI number — HEMOPHILIA OF GEORGIA

Table of content: (NPI 1699778563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699778563 NPI number — HEMOPHILIA OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEMOPHILIA OF GEORGIA
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:
HEMOPHILIA OF GEORGIA
Provider Other Organization Name Type Code:
3
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:
1699778563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8800 ROSWELL RD
Provider Second Line Business Mailing Address:
STE 170
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30350-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-518-8272
Provider Business Mailing Address Fax Number:
770-518-3310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8800 ROSWELL RD
Provider Second Line Business Practice Location Address:
STE 170
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30350-1826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-518-8272
Provider Business Practice Location Address Fax Number:
770-518-3310
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOOVER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, OPERATIONS
Authorized Official Telephone Number:
770-518-8272

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHRE007480 , 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: 00528393A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2018678 . This is a "PK" identifier . This identifiers is of the category "OTHER".