Basic Information
| Provider Information | |||||||||
| NPI: | 1972138790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL UNIVERSITY HOSPITAL AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 931854 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311931854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437922311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437921414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAE | ||||||||
| AuthorizedOfficialFirstName: | KARYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8438761344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator |
No ID Information.