1366542490 NPI number — SOUTHSIDE ASSOCIATES OB/GYN, INC

Table of content: (NPI 1366542490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366542490 NPI number — SOUTHSIDE ASSOCIATES OB/GYN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE ASSOCIATES OB/GYN, 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:
1366542490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 CLEVELAND AVE
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
EAST POINT
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30344-3618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-768-3487
Provider Business Mailing Address Fax Number:
404-768-1051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 CLEVELAND AVE
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-3618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-768-3487
Provider Business Practice Location Address Fax Number:
404-768-1051
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREEMONT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
MCKINLEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-768-3487

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  016343 , 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: 00117752A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00117752F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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