1073140927 NPI number — PREMIERCARE OMEGA

Table of content: (NPI 1073140927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073140927 NPI number — PREMIERCARE OMEGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERCARE OMEGA
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:
1073140927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 MOORE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMEGA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31775-3075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-528-6500
Provider Business Mailing Address Fax Number:
229-528-3283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 MOORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMEGA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31775-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-528-6500
Provider Business Practice Location Address Fax Number:
229-528-3283
Provider Enumeration Date:
03/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
CLYDE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
229-387-4802

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 256884477 . This is a "FAMILY MEDICINE" identifier . This identifiers is of the category "OTHER".




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