1992942759 NPI number — PSYCHIATRY ASSOCIATES OF GEORGIA PC

Table of content: (NPI 1992942759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992942759 NPI number — PSYCHIATRY ASSOCIATES OF GEORGIA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRY ASSOCIATES OF GEORGIA 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:
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:
1992942759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 870972
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-0025
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:
130 EAGLE SPRING CT
Provider Second Line Business Practice Location Address:
SUITE 100A
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-7274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-284-0133
Provider Business Practice Location Address Fax Number:
678-284-6393
Provider Enumeration Date:
01/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GULATI
Authorized Official First Name:
BRIJ
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MD/VICE PRESIDENT
Authorized Official Telephone Number:
678-284-0133

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  52570 , 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: 241352090C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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