1972929685 NPI number — WITHINME MD, ATLANTA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972929685 NPI number — WITHINME MD, ATLANTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WITHINME MD, ATLANTA
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:
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:
1972929685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 GLEN IRIS DR NE
Provider Second Line Business Mailing Address:
5275 LEE HIGHWAY #201, ARLINGTON, VIRGINIA 22207
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30308-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-464-8169
Provider Business Mailing Address Fax Number:
404-921-9577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 GLEN IRIS DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-464-8169
Provider Business Practice Location Address Fax Number:
404-921-9577
Provider Enumeration Date:
03/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
DERRON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL DIRECTOR
Authorized Official Telephone Number:
804-441-5040

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  1366405037 , 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)





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