1760445712 NPI number — DR. GENEVIEVE L FAIRBROTHER M.D.

Table of content: DR. GENEVIEVE L FAIRBROTHER M.D. (NPI 1760445712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760445712 NPI number — DR. GENEVIEVE L FAIRBROTHER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRBROTHER
Provider First Name:
GENEVIEVE
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1760445712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5780 PEACHTREE DUNWOODY ROAD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-1513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-303-1224
Provider Business Mailing Address Fax Number:
404-303-1325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3890 JOHNS CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-1284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-775-2300
Provider Business Practice Location Address Fax Number:
678-775-2359
Provider Enumeration Date:
04/10/2006

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: 174400000X , with the licence number:  037531 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 037531 , 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: 000720486K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000720486L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000720486J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000720486M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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