1578945606 NPI number — MS. SAMATRA L PHILLIPS MA, MAC, ICAADC, CPR

Table of content: MS. SAMATRA L PHILLIPS MA, MAC, ICAADC, CPR (NPI 1578945606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578945606 NPI number — MS. SAMATRA L PHILLIPS MA, MAC, ICAADC, CPR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
SAMATRA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, MAC, ICAADC, CPR
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:
1578945606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4868 OZMENT TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30038-6208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-838-1271
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6800 DAHLONEGA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30028-5595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-838-1271
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2015

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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