1871635516 NPI number — M. MICHAEL PULLIAM, M.D., P.C.

Table of content: (NPI 1871635516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871635516 NPI number — M. MICHAEL PULLIAM, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M. MICHAEL PULLIAM, M.D., P.C.
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:
6
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:
1871635516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30015-0469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-786-1234
Provider Business Mailing Address Fax Number:
770-385-0813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1467 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-786-1234
Provider Business Practice Location Address Fax Number:
770-385-0813
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PULLIAM
Authorized Official First Name:
MORRIS
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-786-1234

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  11036 , 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: 00012229D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00164469K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00164469I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00164469J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00420802A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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