1063538924 NPI number — SOUTH DEKALB PRIMARY CARE, PC

Table of content: (NPI 1063538924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063538924 NPI number — SOUTH DEKALB PRIMARY CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH DEKALB PRIMARY CARE, 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:
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:
1063538924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 COLUMBIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30032-2824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-289-1952
Provider Business Mailing Address Fax Number:
404-289-1953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 COLUMBIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30032-2824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-289-1952
Provider Business Practice Location Address Fax Number:
404-289-1953
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WELCH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECT OWNER
Authorized Official Telephone Number:
404-289-1952

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  156445 , 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: 156445 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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