1972148708 NPI number — ROBERT LAND PA

Table of content: TESSA DAMARIS EDWARDS (NPI 1588423321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972148708 NPI number — ROBERT LAND PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAND
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

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:
1972148708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 BROAD ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABBEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31001-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-467-3209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 BROAD ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABBEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31001-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-467-3209
Provider Business Practice Location Address Fax Number:
229-467-3212
Provider Enumeration Date:
11/15/2019

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: 363A00000X , with the licence number:  11017 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 3418 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 11017 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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