1891732020 NPI number — LEAH ANN BULOW MSPT

Table of content: LEAH ANN BULOW MSPT (NPI 1891732020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891732020 NPI number — LEAH ANN BULOW MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULOW
Provider First Name:
LEAH
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BULOW-LONG
Provider Other First Name:
LEAH
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891732020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8823 PRODUCTION LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OOLTEWAH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37363-6511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 TOWNE LAKE PKWY
Provider Second Line Business Practice Location Address:
BLDG. 1200, SUITES 100 & 110
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-5540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-926-2744
Provider Business Practice Location Address Fax Number:
770-926-2794
Provider Enumeration Date:
05/31/2006

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: 225100000X , with the licence number:  PT7777 , 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: 507154480A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 985630 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 507154480B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 985629 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 985631 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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