Basic Information
Provider Information | |||||||||
NPI: | 1689656514 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUEY | ||||||||
FirstName: | JARROD | ||||||||
MiddleName: | DWAYNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1950 | ||||||||
Address2: |   | ||||||||
City: | DOUGLASVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301331950 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7066608505 | ||||||||
FaxNumber: | 7066609390 | ||||||||
Practice Location | |||||||||
Address1: | 8954 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | DOUGLASVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301342272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709206413 | ||||||||
FaxNumber: | 6788382532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 01/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036158963 | IL | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 048863 | GA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 048863 | GA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 756278717A | 05 | GA |   | MEDICAID | 491431789A | 05 | GA |   | MEDICAID |