Basic Information
Provider Information | |||||||||
NPI: | 1699725655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIKE | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | LYNDON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.T., C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120-B OSIGIAN BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310888939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4789535358 | ||||||||
FaxNumber: | 4789535340 | ||||||||
Practice Location | |||||||||
Address1: | 3051 WATSON BLVD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310938536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4789534611 | ||||||||
FaxNumber: | 4789534564 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000381 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.