1811924251 NPI number — TMC INFECTIOUS DISEASES OF WEST GEORGIA

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 1811924251 NPI number — TMC INFECTIOUS DISEASES OF WEST GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMC INFECTIOUS DISEASES OF WEST 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:
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:
1811924251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 AMBULANCE DR
Provider Second Line Business Mailing Address:
AUITE 202
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30117-3857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-836-9250
Provider Business Mailing Address Fax Number:
770-836-9261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 DIXIE ST
Provider Second Line Business Practice Location Address:
C/O ICU
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30117-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-836-9666
Provider Business Practice Location Address Fax Number:
770-838-8922
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACALUSO PEARE
Authorized Official First Name:
DEBBI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCIAL OPERATIONS
Authorized Official Telephone Number:
770-838-8554

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG2920 . This is a "MEDICARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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