1508222993 NPI number — MRS. ROSETTA GOODSON-REDMOND FNP

Table of content: MRS. ROSETTA GOODSON-REDMOND FNP (NPI 1508222993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508222993 NPI number — MRS. ROSETTA GOODSON-REDMOND FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODSON-REDMOND
Provider First Name:
ROSETTA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODSON
Provider Other First Name:
ROSETTA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508222993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 SAVOY DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30341-1072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-228-1767
Provider Business Mailing Address Fax Number:
770-228-7562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 SOUTH 8TH STREET
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GRIFFIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30224-4880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-288-9555
Provider Business Practice Location Address Fax Number:
678-288-9556
Provider Enumeration Date:
01/14/2016

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: 363LF0000X , with the licence number:  F1015699 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: RN171233 , 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: 202I503298 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003173975D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003173975C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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