1699770446 NPI number — JEREMY E LONDON MD

Table of content: JEREMY E LONDON MD (NPI 1699770446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699770446 NPI number — JEREMY E LONDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONDON
Provider First Name:
JEREMY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1699770446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 E 72ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-4913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-7878
Provider Business Mailing Address Fax Number:
912-819-7850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11700 MERCY BLVD.
Provider Second Line Business Practice Location Address:
PLAZA D SUITE A
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-819-0500
Provider Business Practice Location Address Fax Number:
912-819-0501
Provider Enumeration Date:
06/17/2005

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: 208600000X , with the licence number:  050403 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 050403 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 050403 , 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: 000921401E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000921401H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000921401F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000921401G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G22407 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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