1083702641 NPI number — PREMIER ORTHOPEDICS PC

Table of content: (NPI 1083702641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083702641 NPI number — PREMIER ORTHOPEDICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ORTHOPEDICS 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:
1083702641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70969
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31708-0969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-435-1458
Provider Business Mailing Address Fax Number:
229-317-2342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 OSLER CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-0214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-435-1458
Provider Business Practice Location Address Fax Number:
229-317-2342
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGEE
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
229-435-1458

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  207X00000X , 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: 208016568A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF3058 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com