1235177379 NPI number — EMORY MEDICAL AFFILIATES, INC

Table of content: (NPI 1235177379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235177379 NPI number — EMORY MEDICAL AFFILIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMORY MEDICAL AFFILIATES, INC
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:
1235177379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W PONCE DE LEON AVE
Provider Second Line Business Mailing Address:
SUITE 420
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30030-2533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-778-7525
Provider Business Mailing Address Fax Number:
404-778-7823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1845 SATELLITE BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-4061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-778-5220
Provider Business Practice Location Address Fax Number:
770-995-8455
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTELLANO
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-778-5232

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2002000727 , 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)





Copyright © 2007-2025 www.npivalidator.com