1073049953 NPI number — SYNERGY MEDICAL GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073049953 NPI number — SYNERGY MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY MEDICAL GROUP, LLC
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:
1073049953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 SANDY SPRINGS PL
Provider Second Line Business Mailing Address:
STE. D-120
Provider Business Mailing Address City Name:
SANDY SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6690 ROSWELL RD
Provider Second Line Business Practice Location Address:
STE.520
Provider Business Practice Location Address City Name:
SANDY SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-3161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-999-8531
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LUNDRIGAN
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERD AGEN
Authorized Official Telephone Number:
678-230-7138

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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