1376574863 NPI number — MICHAEL DAREN MUDREY DO

Table of content: MICHAEL DAREN MUDREY DO (NPI 1376574863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376574863 NPI number — MICHAEL DAREN MUDREY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUDREY
Provider First Name:
MICHAEL
Provider Middle Name:
DAREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1376574863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1332
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC CAYSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30555-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-632-3711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3540 COBB PKWY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ACWORTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-3711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  038564 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 38564 , 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: 000621398J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015844700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com