1821440819 NPI number — SOUTHERN LUNG SPECIALISTS PC

Table of content: (NPI 1821440819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821440819 NPI number — SOUTHERN LUNG SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN LUNG SPECIALISTS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821440819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 PINE ST
Provider Second Line Business Mailing Address:
SUITE 560
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-745-9998
Provider Business Mailing Address Fax Number:
478-745-9981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 PINE ST
Provider Second Line Business Practice Location Address:
SUITE 560
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-7569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-745-9998
Provider Business Practice Location Address Fax Number:
478-745-9981
Provider Enumeration Date:
07/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TARRIAH
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
478-745-9998

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DW7232 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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