1104288240 NPI number — DR. SUSAN ELIZABETH NORTHRUP M.D., M.P.H

Table of content: KOURTNEY MANTYLA-MURPHY NP (NPI 1942987334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104288240 NPI number — DR. SUSAN ELIZABETH NORTHRUP M.D., M.P.H

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORTHRUP
Provider First Name:
SUSAN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., M.P.H
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:
1104288240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 COLUMBIA AVE
Provider Second Line Business Mailing Address:
FEDERAL AVIATION ADMINISTRATION, ASO-300
Provider Business Mailing Address City Name:
COLLEGE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30337-2714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-305-6150
Provider Business Mailing Address Fax Number:
404-305-6161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 COLUMBIA AVENUE
Provider Second Line Business Practice Location Address:
FEDERAL AVIATION ADMINISTRATION, ASO-300
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-305-6150
Provider Business Practice Location Address Fax Number:
404-305-6161
Provider Enumeration Date:
03/28/2016

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: 2083A0100X , with the licence number:  54426 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2083X0100X , with the licence number: 54426 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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