1780620930 NPI number — MR. ROBERT MARTIN MCKENNA JR. PA C

Table of content: MR. ROBERT MARTIN MCKENNA JR. PA C (NPI 1780620930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780620930 NPI number — MR. ROBERT MARTIN MCKENNA JR. PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENNA
Provider First Name:
ROBERT
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
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:
1780620930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5667 PEACHTREE DUNWOODY RD, NE
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342-1725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-252-7200
Provider Business Mailing Address Fax Number:
404-252-7397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5667 PEACHTREE DUNWOODY RD, NE
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-252-7200
Provider Business Practice Location Address Fax Number:
404-252-7397
Provider Enumeration Date:
06/22/2006

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: 363AM0700X , with the licence number:  A676 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0033PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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