1164429692 NPI number — GLYNN COUNTY BOARD OF HEALTH

Table of content: (NPI 1164429692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164429692 NPI number — GLYNN COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLYNN COUNTY BOARD OF HEALTH
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:
6
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:
1164429692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 SCRANTON CONNECTOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31525-0540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-262-2347
Provider Business Mailing Address Fax Number:
912-262-3036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2747 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-264-3236
Provider Business Practice Location Address Fax Number:
912-262-3051
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
STACY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
DISTRICT BILLING DEPT. COORDINATOR
Authorized Official Telephone Number:
912-262-2347

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: FLU143 . This is a "MEDICARE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000456508P , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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