1659446979 NPI number — MRS. MEGAN KATE SMITH P.T.

Table of content: MRS. MEGAN KATE SMITH P.T. (NPI 1659446979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659446979 NPI number — MRS. MEGAN KATE SMITH P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MEGAN
Provider Middle Name:
KATE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1659446979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 SAGEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTERVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30683-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-742-5758
Provider Business Mailing Address Fax Number:
603-843-2144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 SAGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTERVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30683-1563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-742-5758
Provider Business Practice Location Address Fax Number:
603-843-2144
Provider Enumeration Date:
11/21/2006

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: 225100000X , with the licence number:  PT006029 , 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: 10040251 . This is a "AMERIGROUP PROVIDER NUM" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 322000 . This is a "WELLCARE POVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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