1831333012 NPI number — ALISA ANN ERRIDGE MSPAS

Table of content: ALISA ANN ERRIDGE MSPAS (NPI 1831333012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831333012 NPI number — ALISA ANN ERRIDGE MSPAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERRIDGE
Provider First Name:
ALISA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPAS
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:
1831333012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 COLLIER ROAD, NW
Provider Second Line Business Mailing Address:
SUITE 5015
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-605-5699
Provider Business Mailing Address Fax Number:
404-355-4235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 COLLIER ROAD, NW
Provider Second Line Business Practice Location Address:
SUITE 5015
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30309-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-605-5699
Provider Business Practice Location Address Fax Number:
404-355-4235
Provider Enumeration Date:
05/01/2009

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: 363AS0400X , with the licence number:  005542 , 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: 003106435A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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