1407973936 NPI number — GENESYS FAMILY PRACTICE, INC.

Table of content: (NPI 1407973936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407973936 NPI number — GENESYS FAMILY PRACTICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESYS FAMILY PRACTICE, 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:
1407973936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 HANDLEY RD
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
TYRONE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-964-5810
Provider Business Mailing Address Fax Number:
678-364-1216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 HANDLEY RD
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
TYRONE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-964-5810
Provider Business Practice Location Address Fax Number:
678-364-1216
Provider Enumeration Date:
03/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
IVY
Authorized Official Middle Name:
YVONNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-964-5810

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  053075 , 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: 407530212B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 088BRJB . This is a "MEDICARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".