Basic Information
Provider Information | |||||||||
NPI: | 1003020967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DENIS MORIN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BUCHANAN MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 BUCHANAN BYP | ||||||||
Address2: |   | ||||||||
City: | BUCHANAN | ||||||||
State: | GA | ||||||||
PostalCode: | 301134924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706468281 | ||||||||
FaxNumber: | 7706463579 | ||||||||
Practice Location | |||||||||
Address1: | 30 BUCHANAN BYP | ||||||||
Address2: |   | ||||||||
City: | BUCHANAN | ||||||||
State: | GA | ||||||||
PostalCode: | 301134924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706468281 | ||||||||
FaxNumber: | 7706463579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 07/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COGGINS | ||||||||
AuthorizedOfficialFirstName: | MELANIE | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7706468281 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 024466 | GA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 113959 | 01 |   | RURAL HEALTH MEDICARE PIN | OTHER | DD7682 | 01 |   | RAILROAD MEDICARE PIN | OTHER | 231090380A | 05 | GA |   | MEDICAID |