Basic Information
| Provider Information | |||||||||
| NPI: | 1669669412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEMOINE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508180 | ||||||||
| FaxNumber: | 9123505697 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508180 | ||||||||
| FaxNumber: | 9123505697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 63545441204 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 066712 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 066712 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003111892A | 05 | GA | MEDICAID | 618879 | 01 | GA | WELLCARE | OTHER | GA1252 | 05 | SC | MEDICAID | P00999566 | 01 | GA | RAILROAD MEDICARE | OTHER |