1922081330 NPI number — TAMARA LYNN MARSHALL P.A.A.A.

Table of content: TAMARA LYNN MARSHALL P.A.A.A. (NPI 1922081330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922081330 NPI number — TAMARA LYNN MARSHALL P.A.A.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
TAMARA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.A.A.
Provider Gender Code:
F

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:
1922081330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5665 NEW NORTHSIDE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-874-5400
Provider Business Mailing Address Fax Number:
770-874-6897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8954 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-920-6413
Provider Business Practice Location Address Fax Number:
678-838-2532
Provider Enumeration Date:
11/21/2005

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: 363A00000X , with the licence number:  002716 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367H00000X , with the licence number: 002716 , 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: 491431789A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 199727917A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".