1558797514 NPI number — KASSIE D. MIDDLEBROOKS MPAS, PA-C

Table of content: KASSIE D. MIDDLEBROOKS MPAS, PA-C (NPI 1558797514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558797514 NPI number — KASSIE D. MIDDLEBROOKS MPAS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIDDLEBROOKS
Provider First Name:
KASSIE
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPAS, PA-C
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:
1558797514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
706-494-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-2561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-274-8886
Provider Business Practice Location Address Fax Number:
478-274-8887
Provider Enumeration Date:
09/23/2013

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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