1124086020 NPI number — MILTONIA M WOLUCHEM MD

Table of content: MILTONIA M WOLUCHEM MD (NPI 1124086020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124086020 NPI number — MILTONIA M WOLUCHEM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLUCHEM
Provider First Name:
MILTONIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARVEY
Provider Other First Name:
MILTONIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124086020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1331 MOUNT ZION RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORROW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30260-2357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-629-3217
Provider Business Mailing Address Fax Number:
404-666-0085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 MOUNT ZION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORROW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30260-2357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-629-3217
Provider Business Practice Location Address Fax Number:
404-666-0085
Provider Enumeration Date:
05/02/2006

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: 207R00000X , with the licence number:  196867 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 76541 , 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: 619687-6W . This is a "WORKERS COMP #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 051101000018 . This is a "FIDELIS CARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0414039 . This is a "IHA #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9250 . This is a "SIDNEY HILLMAN #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: MDH910 . This is a "PREFERRED CARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010196867 . This is a "BLUE CHOICE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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