Basic Information
Provider Information | |||||||||
NPI: | 1811178569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATHENS ATTENTIVE MD, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5779 | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306045779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063545770 | ||||||||
FaxNumber: | 7063545769 | ||||||||
Practice Location | |||||||||
Address1: | 455 EPPS BRIDGE PKWY | ||||||||
Address2: | BUILDING 100, SUITE 102 | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306063347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063532778 | ||||||||
FaxNumber: | 7063545769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2007 | ||||||||
LastUpdateDate: | 11/23/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WINGATE | ||||||||
AuthorizedOfficialFirstName: | HARRY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7063545770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 032498 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.