1942296660 NPI number — TOM M FAZLOLLAH CRNA

Table of content: TOM M FAZLOLLAH CRNA (NPI 1942296660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942296660 NPI number — TOM M FAZLOLLAH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAZLOLLAH
Provider First Name:
TOM
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1942296660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MANSELL CT E
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DEPT., SUITE 105
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-4856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-645-9181
Provider Business Mailing Address Fax Number:
770-645-8455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 JOHNSON FERRY RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-645-9181
Provider Business Practice Location Address Fax Number:
770-645-8455
Provider Enumeration Date:
09/27/2005

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: 367500000X , with the licence number:  RN047276 , 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)





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