Basic Information
| Provider Information | |||||||||
| NPI: | 1649219429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FABRIZIO | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | V. R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARDSON | ||||||||
| OtherFirstName: | ADRIENNE | ||||||||
| OtherMiddleName: | VICTORIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 310 EISENHOWER DR | ||||||||
| Address2: | STE 12A | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314062632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122011140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 EISENHOWER DR STE 12A | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314062632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122011140 | ||||||||
| FaxNumber: | 9123524065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 050365 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 349759 | 01 | GA | WELLCARE MEDICAID | OTHER | 619151 | 01 | GA | WELLCARE | OTHER | 890274 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000926978C | 05 | GA | MEDICAID | G50365 | 05 | SC | MEDICAID | 000926978A | 05 | GA | MEDICAID | 10064422 | 01 | GA | AMERIGROUP | OTHER | 110234552 | 01 | RAILROAD MEDICARE | OTHER |