1467582809 NPI number — MR. ALAN JAY GRODIN PT

Table of content: MR. ALAN JAY GRODIN PT (NPI 1467582809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467582809 NPI number — MR. ALAN JAY GRODIN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRODIN
Provider First Name:
ALAN
Provider Middle Name:
JAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1467582809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CAMERON GLEN DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-4707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
779-937-0068
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3280 HOWELL MILL RD NW
Provider Second Line Business Practice Location Address:
SUITE 139
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30327-4111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-310-4277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

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: 225100000X , with the licence number:  1153 , 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: 1153 . This is a "PHYSICAL THERAPIST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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