1760544902 NPI number — SUSAN B WILLIAMSON OTRL

Table of content: SUSAN B WILLIAMSON OTRL (NPI 1760544902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760544902 NPI number — SUSAN B WILLIAMSON OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMSON
Provider First Name:
SUSAN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
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:
1760544902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 VAN AALST BLVD BLDG 9250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MOORE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31905-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-545-9114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 VAN AALST BLVD BLDG 9250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MOORE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31905-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-545-9114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2006

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: 225X00000X , with the licence number:  OT000629 , 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: 52670844-001 . This is a "BCBS OF GA PROVIDER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000748822D . This is a "PEACH STATE PROVIDER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 335026 . This is a "WELLCARE PROVIDER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000748822D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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