1871707489 NPI number — COKER PEDIATRICS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871707489 NPI number — COKER PEDIATRICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COKER PEDIATRICS LLC
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:
1871707489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14557 HIGHWAY 19
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GRIFFIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30224-9582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-688-1580
Provider Business Mailing Address Fax Number:
678-688-1594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14557 HIGHWAY 19
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GRIFFIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30224-9582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-688-1580
Provider Business Practice Location Address Fax Number:
678-688-1594
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COKER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
678-688-1580

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  056276 , 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: 579118048J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com