Basic Information
Provider Information | |||||||||
NPI: | 1548273592 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIEDMONT PROVIDERS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102321 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708012500 | ||||||||
FaxNumber: | 7708032121 | ||||||||
Practice Location | |||||||||
Address1: | 220 J L WHITE DR STE 120 | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | GA | ||||||||
PostalCode: | 301434894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708012500 | ||||||||
FaxNumber: | 7708032121 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 10/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AQUINO | ||||||||
AuthorizedOfficialFirstName: | CHRISTY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 4702713427 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 306264909A | 05 | GA |   | MEDICAID | GRP3809 | 01 | GA | MEDICARE | OTHER | CH4995 | 01 | GA | RR MEDICARE | OTHER |