1386241925 NPI number — CLINT R HEGER MA, ICADCII

Table of content: KARA ELIZABETH PHILLIPS PHARMD (NPI 1881560365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386241925 NPI number — CLINT R HEGER MA, ICADCII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEGER
Provider First Name:
CLINT
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ICADCII
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:
1386241925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 WOOD CREEK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-1998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
44-606-2138
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2855 LAWRENCEVILLE SUWANEE RD STE 330
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-3572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-904-3955
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2020

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: 101YA0400X , with the licence number:  1105 , 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: 574369K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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