1366564270 NPI number — DR. GIGI DENEAN BELL-WADE M.D.

Table of content: DR. GIGI DENEAN BELL-WADE M.D. (NPI 1366564270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366564270 NPI number — DR. GIGI DENEAN BELL-WADE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BELL-WADE
Provider First Name:
GIGI
Provider Middle Name:
DENEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1366564270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MABLETON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30126-1003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-819-1635
Provider Business Mailing Address Fax Number:
770-819-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4955 RIDGE OAK RUN SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MABLETON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30126-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-819-1635
Provider Business Practice Location Address Fax Number:
770-819-1635
Provider Enumeration Date:
04/04/2007

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: 207L00000X , with the licence number:  042524 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: 042524 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00720926B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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