1346420858 NPI number — ADVANCED SURGICAL SPECIALISTS OF NORTHEAST GEORGIA, LLC

Table of content: (NPI 1346420858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346420858 NPI number — ADVANCED SURGICAL SPECIALISTS OF NORTHEAST GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SURGICAL SPECIALISTS OF NORTHEAST GEORGIA, LLC
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:
1346420858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1359 MILSTEAD RD NE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30012-3865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-413-2182
Provider Business Mailing Address Fax Number:
678-413-2184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1359 MILSTEAD RD NE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30012-3865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-413-2182
Provider Business Practice Location Address Fax Number:
678-413-2184
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
KERMIE
Authorized Official Middle Name:
LENARD
Authorized Official Title or Position:
OWNER, SOLE PROPRIETER
Authorized Official Telephone Number:
678-413-2182

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  033440 , 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: 000458092C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE9275 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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