1578869046 NPI number — DR. DONALD RUBERTINO POWELL DPM

Table of content: DR. DONALD RUBERTINO POWELL DPM (NPI 1578869046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578869046 NPI number — DR. DONALD RUBERTINO POWELL DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
DONALD
Provider Middle Name:
RUBERTINO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOSLEY
Provider Other First Name:
DONALD
Provider Other Middle Name:
KIRK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578869046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1975 HIGHWAY 54 W
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-4794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-561-9000
Provider Business Mailing Address Fax Number:
770-487-1232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 PEACHTREE ST NE
Provider Second Line Business Practice Location Address:
STE 1615
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-702-0620
Provider Business Practice Location Address Fax Number:
678-702-0621
Provider Enumeration Date:
02/01/2011

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: 213ES0103X , with the licence number:  POD00135 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: PO3482 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003131663C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202I487348 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003131663B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003131663A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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