1972689347 NPI number — DR. ANDREI PETROVICH BOURDEINYI D.C.

Table of content: (NPI 1285990952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972689347 NPI number — DR. ANDREI PETROVICH BOURDEINYI D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURDEINYI
Provider First Name:
ANDREI
Provider Middle Name:
PETROVICH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1972689347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1625 ROSWELL RD
Provider Second Line Business Mailing Address:
APT.138
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-3682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3155 ROSWELL RD NE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30305-1821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-231-1000
Provider Business Practice Location Address Fax Number:
404-231-5546
Provider Enumeration Date:
10/28/2006

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: 111N00000X , with the licence number:  CHIR006547 , 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: 11303651 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7467540 . This is a "AETNA INSURANCE COMPANY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 649113 . This is a "UNITED HEALTH CARE INS.CO" identifier . This identifiers is of the category "OTHER".




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