Basic Information
Provider Information | |||||||||
NPI: | 1255374625 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAGE | ||||||||
FirstName: | DEXTER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 PEACHTREE STREET, NE | ||||||||
Address2: | SUITE 1275 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4048723121 | ||||||||
FaxNumber: | 4048723119 | ||||||||
Practice Location | |||||||||
Address1: | 550 PEACHTREE STREET, NE | ||||||||
Address2: | SUITE 1275 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4048723121 | ||||||||
FaxNumber: | 4048723119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 040974 | GA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
ID | Type | State | Issuer | Description | 000678906N | 05 | GA |   | MEDICAID | 000678906C | 05 | GA |   | MEDICAID | 000678906G | 05 | GA |   | MEDICAID | 000678906P | 05 | GA |   | MEDICAID | 000678906D | 05 | GA |   | MEDICAID | 000678906T | 05 | GA |   | MEDICAID | 000678906E | 05 | GA |   | MEDICAID | 000678906Q | 05 | GA |   | MEDICAID | 000678906 | 05 | GA |   | MEDICAID | 000678906H | 05 | GA |   | MEDICAID | 000678906AA | 05 | GA |   | MEDICAID |