1962561811 NPI number — MPPG, INC.

Table of content: (NPI 1962561811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962561811 NPI number — MPPG, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MPPG, 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:
1962561811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102032
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-2032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-350-5908
Provider Business Mailing Address Fax Number:
912-350-5914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4750 WATERS AVE
Provider Second Line Business Practice Location Address:
SUITE 452
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31404-6200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-350-5908
Provider Business Practice Location Address Fax Number:
912-350-5914
Provider Enumeration Date:
12/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MADDOX
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PROVIDER ENROLLMENT COORDINATOR
Authorized Official Telephone Number:
912-350-9335

Provider Taxonomy Codes

  • Taxonomy code: 133VN1006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GPA603 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300031676A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH5121 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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