1689790867 NPI number — MEDSIDE PALLIATIVE CARE

Table of content: (NPI 1689790867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689790867 NPI number — MEDSIDE PALLIATIVE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSIDE PALLIATIVE CARE
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:
MEDSIDE
Provider Other Organization Name Type Code:
3
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:
1689790867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190996
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31119-0996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-633-7433
Provider Business Mailing Address Fax Number:
888-633-7430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3384 PEACHTREE RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30326-1181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-633-7433
Provider Business Practice Location Address Fax Number:
888-633-7430
Provider Enumeration Date:
03/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KORABELNIKOVA
Authorized Official First Name:
YULIYA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHA/ADMINISTRATOR
Authorized Official Telephone Number:
404-633-7433

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00849527A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060-R-0068 . This is a "MEDSIDE HOME CARE AGENCY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0606-245-H . This is a "STATE ID LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1306858121 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".