1245224344 NPI number — DR. DANIEL BRADLEY LORD M.D.

Table of content: DR. DANIEL BRADLEY LORD M.D. (NPI 1245224344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245224344 NPI number — DR. DANIEL BRADLEY LORD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LORD
Provider First Name:
DANIEL
Provider Middle Name:
BRADLEY
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:
1245224344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 WELLNESS WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-995-7989
Provider Business Mailing Address Fax Number:
770-339-8646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3855 PLEASANT HILL ROAD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-495-8300
Provider Business Practice Location Address Fax Number:
770-495-7646
Provider Enumeration Date:
09/02/2005

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: 207RG0100X , with the licence number:  038852 , 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: 6943 . This is a "PROMINA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4575100 . This is a "MANAGE CARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 7462612 . This is a "CIGNA PPO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 100012565 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 29-06974 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 582061514003 . This is a "PRUDENTIAL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 6943 . This is a "ONE HEALTH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000623136A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52495718 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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