1568508893 NPI number — DR. JASON ALEXANDER PETROFSKI MD

Table of content: DR. JASON ALEXANDER PETROFSKI MD (NPI 1568508893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568508893 NPI number — DR. JASON ALEXANDER PETROFSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETROFSKI
Provider First Name:
JASON
Provider Middle Name:
ALEXANDER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1568508893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 NORTHSIDE BLVD
Provider Second Line Business Mailing Address:
SUITE 1900
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30041-7623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-341-3764
Provider Business Mailing Address Fax Number:
678-341-3769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 NORTHSIDE BLVD
Provider Second Line Business Practice Location Address:
SUITE 1900
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-7623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-341-3764
Provider Business Practice Location Address Fax Number:
678-341-3769
Provider Enumeration Date:
01/30/2007

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: 208C00000X , with the licence number:  059311 , 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: 236918506A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 236918506E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 236918506D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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