1194776914 NPI number — COVENANT EMERGENCY PHYSICIANS LLC

Table of content: (NPI 1194776914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194776914 NPI number — COVENANT EMERGENCY PHYSICIANS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT EMERGENCY PHYSICIANS LLC
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:
1194776914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 BARRON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30523-5501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
706-754-1011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 HISTORIC HWY 441
Provider Second Line Business Practice Location Address:
ER DEPARTMENT
Provider Business Practice Location Address City Name:
DEMOREST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-754-3113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHETTA
Authorized Official First Name:
MARC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-754-3113

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE8501 . This is a "RRGA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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