Basic Information
Provider Information | |||||||||
NPI: | 1760452783 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RANGE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | NEEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 658 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305030658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707181122 | ||||||||
FaxNumber: | 7705357445 | ||||||||
Practice Location | |||||||||
Address1: | 4222 FAIRBANKS DR | ||||||||
Address2: |   | ||||||||
City: | OAKWOOD | ||||||||
State: | GA | ||||||||
PostalCode: | 305662811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705346053 | ||||||||
FaxNumber: | 7705346695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 10/26/2018 | ||||||||
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 | 208D00000X | 021274 | GA | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 10045373 | 01 | GA | AMERIGROUP | OTHER | 6679698 | 01 | GA | CIGNA | OTHER | 80075271 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER | 341308 | 01 | GA | WELLCARE | OTHER | 4105859 | 01 | GA | AETNA PPO | OTHER | 52046825 | 01 | GA | BCBS | OTHER | 000252755C | 05 | GA |   | MEDICAID | 0100290 | 01 | GA | UNITED HEALTHCARE | OTHER |