1487064051 NPI number — PHYSICIAN DISABILITY EXAMINATION SERVICES INC

Table of content: (NPI 1487064051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487064051 NPI number — PHYSICIAN DISABILITY EXAMINATION SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN DISABILITY EXAMINATION SERVICES 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:
6
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:
1487064051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 SUGARLOAF PKWY
Provider Second Line Business Mailing Address:
SUITE 400 #290
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-573-0039
Provider Business Mailing Address Fax Number:
888-684-8452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 W 3RD AVE STE 8A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31701-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-589-9064
Provider Business Practice Location Address Fax Number:
888-684-8452
Provider Enumeration Date:
05/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
RASHEEDA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
229-573-0039

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  OS10135 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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