1982834081 NPI number — DR. MARY LYNN EPSTEN CHILLEMI MD

Table of content: DR. MARY LYNN EPSTEN CHILLEMI MD (NPI 1982834081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982834081 NPI number — DR. MARY LYNN EPSTEN CHILLEMI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILLEMI
Provider First Name:
MARY LYNN
Provider Middle Name:
EPSTEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EPSTEN
Provider Other First Name:
MARY LYNN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982834081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 JESSE JEWELL PKWY SE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501-3861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-532-7202
Provider Business Mailing Address Fax Number:
251-434-3802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 SPRING HILL AVE
Provider Second Line Business Practice Location Address:
SUITE 1600
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36604-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-434-3915
Provider Business Practice Location Address Fax Number:
251-434-3802
Provider Enumeration Date:
07/23/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 075040 , 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: 003213684A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06538356 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003213684B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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