1932297868 NPI number — BEVERLY POTTINGER PICKENS D.O.

Table of content: BEVERLY POTTINGER PICKENS D.O. (NPI 1932297868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932297868 NPI number — BEVERLY POTTINGER PICKENS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTINGER PICKENS
Provider First Name:
BEVERLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1932297868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6095 PROFESSIONAL PKWY
Provider Second Line Business Mailing Address:
SUITE A210
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30134-5607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-949-4188
Provider Business Mailing Address Fax Number:
770-949-1614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6095 PROFESSIONAL PKWY
Provider Second Line Business Practice Location Address:
SUITE A210
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-5607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-949-4188
Provider Business Practice Location Address Fax Number:
770-949-1614
Provider Enumeration Date:
10/10/2006

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: 207V00000X , with the licence number:  052002 , 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: 811423149A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com