1104819903 NPI number — DR. JEANNE MARIE PERRINE O.D. PC

Table of content: DR. JEANNE MARIE PERRINE O.D. PC (NPI 1104819903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104819903 NPI number — DR. JEANNE MARIE PERRINE O.D. PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRINE
Provider First Name:
JEANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D. PC
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:
1104819903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/27/2006
NPI Reactivation Date:
04/20/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 PULLIAM ST SW
Provider Second Line Business Mailing Address:
SUITE 139
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30312-2755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-589-8517
Provider Business Mailing Address Fax Number:
404-222-0174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 PULLIAM ST SW
Provider Second Line Business Practice Location Address:
SUITE 139
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30312-2755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-589-8517
Provider Business Practice Location Address Fax Number:
404-222-0174
Provider Enumeration Date:
08/26/2005

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: 152W00000X , with the licence number:  OPT001112 , 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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