1477537322 NPI number — ABIGAIL KAMISHLIAN M.D.

Table of content: ABIGAIL KAMISHLIAN M.D. (NPI 1477537322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477537322 NPI number — ABIGAIL KAMISHLIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAMISHLIAN
Provider First Name:
ABIGAIL
Provider Middle Name:
Provider Name Prefix Text:
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:
1477537322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4905 COURTNEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30297-1427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-366-3636
Provider Business Mailing Address Fax Number:
404-362-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4905 COURTNEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297-1427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-366-3636
Provider Business Practice Location Address Fax Number:
404-362-0808
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: 208000000X , with the licence number:  044580 , 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: 000777741D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305675 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 58-1631879 . This is a "TAX ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 966369 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 260699313 . This is a "TAX ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10038631 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000777741E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000777741G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000777741C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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