1629025143 NPI number — APOGEE MEDICAL GROUP GEORGIA

Table of content: (NPI 1629025143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629025143 NPI number — APOGEE MEDICAL GROUP GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APOGEE MEDICAL GROUP GEORGIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1629025143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25016
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-269-1897
Provider Business Mailing Address Fax Number:
469-249-1170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 DIXIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30117-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-836-9667
Provider Business Practice Location Address Fax Number:
770-838-8931
Provider Enumeration Date:
05/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARWELL
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
602-778-3600

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DF4338 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 117960800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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