1538128848 NPI number — LYNN E EZELL MD

Table of content: LYNN E EZELL MD (NPI 1538128848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538128848 NPI number — LYNN E EZELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZELL
Provider First Name:
LYNN
Provider Middle Name:
E
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:
HENDRIX
Provider Other First Name:
LYNN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538128848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 491028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-605-3247
Provider Business Mailing Address Fax Number:
404-609-6645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1968 PEACHTREE RD NW
Provider Second Line Business Practice Location Address:
PATHOLOGY DEPT
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-605-3247
Provider Business Practice Location Address Fax Number:
404-609-6645
Provider Enumeration Date:
03/23/2006

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: 207ZH0000X , with the licence number:  023981 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 023981 , 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: 00376065B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com