1902021041 NPI number — DR. W ERIC MACLEOD MD

Table of content: DR. W ERIC MACLEOD MD (NPI 1902021041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902021041 NPI number — DR. W ERIC MACLEOD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACLEOD
Provider First Name:
W
Provider Middle Name:
ERIC
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1902021041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 E. DERENNE AVE
Provider Second Line Business Mailing Address:
ATTN: HOPE SAMS
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-644-5300
Provider Business Mailing Address Fax Number:
912-644-3369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DOCTORS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-383-6575
Provider Business Practice Location Address Fax Number:
912-383-6476
Provider Enumeration Date:
04/16/2007

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: 207X00000X , with the licence number:  053861 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X , with the licence number: 053861 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 594551065E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 594551065C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 594551065B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 594551065D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5945510656 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 594551065A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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