1962039420 NPI number — THE M CENTER FOR INTEGRATIVE PEDIATRICS

Table of content: TAYLOR MARIE BLAKE RD (NPI 1588469704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962039420 NPI number — THE M CENTER FOR INTEGRATIVE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE M CENTER FOR INTEGRATIVE PEDIATRICS
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:
1962039420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 UPPER HEMBREE RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-0914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-381-8556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 RESEARCH CT STE 800
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-6606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-381-8556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
MAIA
Authorized Official Middle Name:
ALEES
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
888-381-8556

Provider Taxonomy Codes

  • Taxonomy code: 2080P0008X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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