1215187711 NPI number — COLE BELTON WIBERLEY PAAA

Table of content: COLE BELTON WIBERLEY PAAA (NPI 1215187711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215187711 NPI number — COLE BELTON WIBERLEY PAAA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIBERLEY
Provider First Name:
COLE
Provider Middle Name:
BELTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAAA
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:
1215187711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3155 N POINT PKWY
Provider Second Line Business Mailing Address:
BUILDING F, SUITE 100 ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-5481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-645-9181
Provider Business Mailing Address Fax Number:
770-645-8455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
677 CHURCH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-794-0477
Provider Business Practice Location Address Fax Number:
770-794-3108
Provider Enumeration Date:
09/22/2008

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: 367H00000X , with the licence number:  005429 , 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: 444906161A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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