1851494447 NPI number — CRESCENT PEDIATRICS

Table of content: (NPI 1851494447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851494447 NPI number — CRESCENT PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESCENT PEDIATRICS
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:
1851494447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2925 PREMIERE PKWY
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-495-6222
Provider Business Mailing Address Fax Number:
770-495-9959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2925 PREMIERE PKWY
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-495-6222
Provider Business Practice Location Address Fax Number:
770-495-9959
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONEIT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-495-6222

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  034204 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 034204 , 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: 000449611C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1207077 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4308928 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 72291 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 313452 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52062819002 . This is a "BC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 85001694G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10037067 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 912801 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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