1679584601 NPI number — BADIA MEDICAL, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679584601 NPI number — BADIA MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BADIA MEDICAL, LLC
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:
LIFEGUARD PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1679584601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 PEACOCK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-922-3074
Provider Business Mailing Address Fax Number:
478-922-3076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 PEACOCK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-922-3074
Provider Business Practice Location Address Fax Number:
478-922-3076
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WARE
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
478-922-3074

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  047353 , 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: 000834809 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003171301 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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