1588923254 NPI number — MEREDITH JENNIFER BOLTON M.D.

Table of content: (NPI 1417121948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588923254 NPI number — MEREDITH JENNIFER BOLTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLTON
Provider First Name:
MEREDITH
Provider Middle Name:
JENNIFER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REARDON
Provider Other First Name:
BELINDA
Provider Other Middle Name:
MEREDITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588923254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5780 PEACHTREE DUNWOODY RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342-1513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-548-4272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 PRINCE AVE
Provider Second Line Business Practice Location Address:
BUILDING 3
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-5908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-548-4272
Provider Business Practice Location Address Fax Number:
706-548-9181
Provider Enumeration Date:
05/15/2012

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: 207V00000X , with the licence number:  075955 , 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: GRP3569 . This is a "OPT-OUT" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300034164A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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