1992825152 NPI number — CORY M STANLEY PA

Table of content: CORY M STANLEY PA (NPI 1992825152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992825152 NPI number — CORY M STANLEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANLEY
Provider First Name:
CORY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1992825152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1103 LAKESHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-8390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-275-1860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3245 PEACHTREE PKWY # D188
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:
30024-6054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-353-6843
Provider Business Practice Location Address Fax Number:
912-303-7167
Provider Enumeration Date:
03/30/2007

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: 363A00000X , with the licence number:  0010-01166 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 005034 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9116822 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01061992 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 567447065F . This is a "MEDICAID ID FOR URGENTONE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GPA892 . This is a "MEDICAID GROUP ID FOR URGENTONE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00441750 . This is a "RR MEDICARE ID FOR URGENTONE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0580PA . This is a "MEDICAID ID FOR URGENTONE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 567447065B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 567447065 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 567447065E . This is a "MEDICAID ID FOR URGENTONE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 567447065C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 567447065A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511I970040 . This is a "MEDICARE ID FOR URGENTONE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GPA9002 . This is a "MEDICAID GROUP ID FOR URGENTONE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 567447065D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117200700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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