1659416071 NPI number — TRACY SMITH MAYBERRY

Table of content: (NPI 1659416071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659416071 NPI number — TRACY SMITH MAYBERRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRACY SMITH MAYBERRY
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:
6
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:
1659416071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1683 WASHINGTON ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST POINT
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30344-4265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-766-6400
Provider Business Mailing Address Fax Number:
404-766-6450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1683 WASHINGTON ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-4265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-766-6400
Provider Business Practice Location Address Fax Number:
404-766-6450
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAYBERRY
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
SMITH
Authorized Official Title or Position:
OWNER/PODIATRIST
Authorized Official Telephone Number:
404-766-6400

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  000763 , 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: 480028687 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000672119F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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