1063711380 NPI number — MRS. AMANDA LAUREN MALDONADO RT

Table of content: MRS. AMANDA LAUREN MALDONADO RT (NPI 1063711380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063711380 NPI number — MRS. AMANDA LAUREN MALDONADO RT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALDONADO
Provider First Name:
AMANDA
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RT
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:
1063711380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 SUMMER HILL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND HILL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31324-4530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-342-3663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 DUNCAN DR BLDG 1440
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31409-5107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-315-6464
Provider Business Practice Location Address Fax Number:
913-315-5397
Provider Enumeration Date:
03/25/2011

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: 2471C3401X , with the licence number:  435024 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471C3402X , with the licence number: 435024 , 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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