1003896952 NPI number — EILEEN JAVELLANA MD

Table of content: EILEEN JAVELLANA MD (NPI 1003896952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003896952 NPI number — EILEEN JAVELLANA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAVELLANA
Provider First Name:
EILEEN
Provider Middle Name:
Provider Name Prefix Text:
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:
1003896952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30503-0658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-718-1122
Provider Business Mailing Address Fax Number:
770-533-4786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-207-4373
Provider Business Practice Location Address Fax Number:
770-533-4727
Provider Enumeration Date:
01/18/2006

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: 207RB0002X , with the licence number:  045841 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 045841 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 045841 , 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: 110029C048846 . This is a "TRAILBLAZER HEALTH ENTERPRISES" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 11BDRZS . This is a "MEDICARE CAHABA GBA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000800555B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000800555D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000800555H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000800555N , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 783517 . This is a "ATENA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2448449 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000800555I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10045921 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 582117020 . This is a "TRICARE CERTIFIED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 582117020045 . This is a "TRICARE CERTIFIED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000800555C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110211686 . This is a "RR MEDICARE-GRP # CC4177" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 582117020057 . This is a "TRICARE CERTIFIED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 767999 . This is a "COVENTRY HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000800555F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000800555K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000800555M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110211686 . This is a "PALMETTO RAILROAD MEDICARE PART B" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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