Basic Information
| Provider Information | |||||||||
| NPI: | 1700030624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POODIACK | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ACKERMAN | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709442830 | ||||||||
| FaxNumber: | 6785817170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709442830 | ||||||||
| FaxNumber: | 6785817170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 11/10/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9104850 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 002325 | 01 | GA | STATE MEDICAL LICENSE | OTHER | GRP245 | 01 | GA | MEDICARE, GROUP NUMBER | OTHER |