Provider Demographics
NPI:1801349204
Name:IDAEWOR, REMIGIUS
Entity type:Individual
Prefix:
First Name:REMIGIUS
Middle Name:
Last Name:IDAEWOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 EAGLE SPRING DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6488
Mailing Address - Country:US
Mailing Address - Phone:678-480-5315
Mailing Address - Fax:
Practice Address - Street 1:110 EAGLE SPRING DR
Practice Address - Street 2:SUITE C
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6488
Practice Address - Country:US
Practice Address - Phone:678-480-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP009529163WC1500X, 3747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHCP009529OtherGEORGIA DEPARTMENT OF COMMUNITY HEALTH