1710944681 NPI number — MR. ARCHIE JOEL CHAMPION III PA-C

Table of content: LISA AGUILERA (NPI 1275663718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710944681 NPI number — MR. ARCHIE JOEL CHAMPION III PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMPION
Provider First Name:
ARCHIE
Provider Middle Name:
JOEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
PA-C
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:
1710944681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 FIRST STREET EAST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-4411
Provider Business Mailing Address Fax Number:
912-538-8485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 FIRST STREET EAST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-537-4411
Provider Business Practice Location Address Fax Number:
912-538-8485
Provider Enumeration Date:
04/26/2006

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: 363A00000X , with the licence number:  003747 , 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: 019893311A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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