1578542510 NPI number — DR. JOHN SCOTT BARANCHOK PHD

Table of content: DR. JOHN SCOTT BARANCHOK PHD (NPI 1578542510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578542510 NPI number — DR. JOHN SCOTT BARANCHOK PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARANCHOK
Provider First Name:
JOHN
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1578542510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 RIVERSIDE PKWY NE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-2982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-290-0535
Provider Business Mailing Address Fax Number:
706-290-1421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
504 RIVERSIDE PKWY NE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30161-2982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-290-0535
Provider Business Practice Location Address Fax Number:
706-290-1421
Provider Enumeration Date:
01/10/2006

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: 103G00000X , with the licence number:  2010 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY002010 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000793174C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com