1063570604 NPI number — PROVIDENCE MEDICAL GROUP, PC

Table of content: (NPI 1063570604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063570604 NPI number — PROVIDENCE MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE MEDICAL GROUP, 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:
1063570604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4047
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:
31208-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-856-3213
Provider Business Mailing Address Fax Number:
404-856-3217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 PEACHTREE ST NE
Provider Second Line Business Practice Location Address:
SUITE 1285
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-856-3213
Provider Business Practice Location Address Fax Number:
404-856-3217
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OSINUGA
Authorized Official First Name:
OLADAYO
Authorized Official Middle Name:
ADISA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-684-7111

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  051703 , 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)





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