1134360183 NPI number — SOUTHEASTERN INDEPENDENT PSYCHIATRY, PC

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 1134360183 NPI number — SOUTHEASTERN INDEPENDENT PSYCHIATRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN INDEPENDENT PSYCHIATRY, 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:
1134360183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 ONEILL ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-6023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-235-2475
Provider Business Mailing Address Fax Number:
706-235-2472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 ONEILL ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30161-6023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-235-2475
Provider Business Practice Location Address Fax Number:
706-235-2472
Provider Enumeration Date:
03/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAIPPLE
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-235-2475

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  021410 , 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: 434028712A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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