1972616076 NPI number — DR. GERALYN DATZ PHD

Table of content: DR. GERALYN DATZ PHD (NPI 1972616076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972616076 NPI number — DR. GERALYN DATZ PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DATZ
Provider First Name:
GERALYN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1972616076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1614
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39403-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-255-1618
Provider Business Mailing Address Fax Number:
601-255-1619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 COMMERCE DR
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-1499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-255-1618
Provider Business Practice Location Address Fax Number:
601-255-1619
Provider Enumeration Date:
08/16/2006

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: 103TC0700X , with the licence number:  45736 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0004X , with the licence number: 45-736 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 1140 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0004X , with the licence number: 1140 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 009933077 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06036275 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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