1053627703 NPI number — NEOCARE OF CENTRAL GEORGIA, PC

Table of content: (NPI 1053627703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053627703 NPI number — NEOCARE OF CENTRAL GEORGIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEOCARE OF CENTRAL GEORGIA, PC
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:
6
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:
1053627703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3203 VINEVILLE AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31204-2323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-471-0273
Provider Business Mailing Address Fax Number:
478-471-1471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3203 VINEVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31204-2323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-471-0273
Provider Business Practice Location Address Fax Number:
478-471-1471
Provider Enumeration Date:
08/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HO
Authorized Official First Name:
IRENE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
478-471-0273

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  076861 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000053347C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000262996I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003171965E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003121342G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003177670C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000262996H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000053347D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003171965F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003177670B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003171965D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003177670A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000053347E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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