1952699696 NPI number — DR. OCTAVIA AMAECHI MD

Table of content: DR. OCTAVIA AMAECHI MD (NPI 1952699696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952699696 NPI number — DR. OCTAVIA AMAECHI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMAECHI
Provider First Name:
OCTAVIA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1952699696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743070
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:
30374-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-560-4304
Provider Business Mailing Address Fax Number:
864-560-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E WOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-560-6193
Provider Business Practice Location Address Fax Number:
864-560-1510
Provider Enumeration Date:
07/15/2011

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: 207Q00000X , with the licence number:  LL33941 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 33941 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SC40915019 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SC40919068 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 339413 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: SC40913365 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SC40916067 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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