1962403865 NPI number — DEKALB MEDICAL CENTER, INC.

Table of content: (NPI 1962403865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962403865 NPI number — DEKALB MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB MEDICAL CENTER, INC.
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:
1962403865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 N DECATUR RD STE 1002B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-5918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-501-5025
Provider Business Mailing Address Fax Number:
404-501-5627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 DEKALB MEDICAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-4996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-501-7534
Provider Business Practice Location Address Fax Number:
404-501-5811
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DAUNT-SAMFORD
Authorized Official First Name:
AVA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
404-501-5025

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  044621 , 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: 100191 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000536U , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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