1982886248 NPI number — OMER L. EUBANKS MD, PC

Table of content: (NPI 1982886248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982886248 NPI number — OMER L. EUBANKS MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMER L. EUBANKS MD, PC
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:
1982886248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1155 HEMBREE RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-740-1753
Provider Business Mailing Address Fax Number:
770-740-8503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 HEMBREE RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-740-1753
Provider Business Practice Location Address Fax Number:
770-740-8503
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EUBANKS
Authorized Official First Name:
OMER
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-740-1753

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  008430 , 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: CL3877 . This is a "PALMETTO GBA - RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 432850 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300028185B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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