1215904909 NPI number — JOSEPH M STILL BURN CENTERS, INC

Table of content: (NPI 1215904909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215904909 NPI number — JOSEPH M STILL BURN CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH M STILL BURN CENTERS, INC
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:
1215904909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30914-3726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-863-9595
Provider Business Mailing Address Fax Number:
706-447-7145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3675 J DEWEY GRAY CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-863-9595
Provider Business Practice Location Address Fax Number:
706-868-8375
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HASSAN
Authorized Official First Name:
S.M.A. ZAHEED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
706-863-9595

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 119108600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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