1457335101 NPI number — DR. GERALD DOMESCIK M.D.

Table of content: DR. GERALD DOMESCIK M.D. (NPI 1457335101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457335101 NPI number — DR. GERALD DOMESCIK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMESCIK
Provider First Name:
GERALD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOMESCIK
Provider Other First Name:
JERRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1457335101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3480 PRESTON RIDGE RD STE 600
Provider Second Line Business Mailing Address:
CREDENTIALING DEPARTMENT
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-5462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-300-0101
Provider Business Mailing Address Fax Number:
770-300-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3193 HOWELL MILL RD NW
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30327-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-355-7591
Provider Business Practice Location Address Fax Number:
404-355-9175
Provider Enumeration Date:
12/05/2005

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: 2085R0202X , with the licence number:  012247 , 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: 000941553I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202G708830 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300122041 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300122052 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000941553E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00098059 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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