1497913867 NPI number — BENADETTE KERUBO MAKORI-NELSON MD

Table of content: BENADETTE KERUBO MAKORI-NELSON MD (NPI 1497913867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497913867 NPI number — BENADETTE KERUBO MAKORI-NELSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAKORI-NELSON
Provider First Name:
BENADETTE
Provider Middle Name:
KERUBO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAKORI
Provider Other First Name:
BENADETTE
Provider Other Middle Name:
KERUBO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497913867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3950 AUSTELL RD
Provider Second Line Business Mailing Address:
BOX 22
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-732-4022
Provider Business Mailing Address Fax Number:
470-732-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 AUSTELL RD
Provider Second Line Business Practice Location Address:
BOX 22
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-732-4022
Provider Business Practice Location Address Fax Number:
470-732-4023
Provider Enumeration Date:
06/01/2008

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 074063 , 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)





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