1316978166 NPI number — EDGAR WOLLAM

Table of content: EDGAR WOLLAM (NPI 1316978166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316978166 NPI number — EDGAR WOLLAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLLAM
Provider First Name:
EDGAR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOLLAM
Provider Other First Name:
GARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316978166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1660 MULKEY RD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-460-2700
Provider Business Mailing Address Fax Number:
770-739-0212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 MULKEY RD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-460-2700
Provider Business Practice Location Address Fax Number:
770-739-0212
Provider Enumeration Date:
07/06/2006

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: 207RN0300X , with the licence number:  19436 , 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: 000146187C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 920632 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000146187E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001416187H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000146187F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110059639 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000146187B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000146187D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 356860 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 581992673003 . This is a "UHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000146187G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03169 . This is a "BCBS GROUP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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