1073765079 NPI number — PAULSEN OB GYN

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 1073765079 NPI number — PAULSEN OB GYN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAULSEN OB GYN
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:
1073765079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5354 REYNOLDS ST
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-6007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-355-2800
Provider Business Mailing Address Fax Number:
912-355-9444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5354 REYNOLDS ST
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-6007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-355-2800
Provider Business Practice Location Address Fax Number:
912-355-9444
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
REGINALD
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
912-355-2800

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  46638 , 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: 00813084A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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