1215956495 NPI number — DR. KELLY BURTON THRASHER M.D.

Table of content: DR. KELLY BURTON THRASHER M.D. (NPI 1215956495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215956495 NPI number — DR. KELLY BURTON THRASHER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THRASHER
Provider First Name:
KELLY
Provider Middle Name:
BURTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1215956495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5885 GLENRIDGE DR NE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-252-7526
Provider Business Mailing Address Fax Number:
404-851-1709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5885 GLENRIDGE DR NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-5512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-252-7526
Provider Business Practice Location Address Fax Number:
404-851-1709
Provider Enumeration Date:
07/19/2006

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:  052491 , 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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