Healthcare Provider Details

I. General information

NPI: 1922540277
Provider Name (Legal Business Name): IRA STEVEN RACADAG APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/04/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 GOLDEN HILLS DR. STE. D
MOUNTAIN CITY GA
30562-2025
US

IV. Provider business mailing address

125 N MAIN ST UNIT 1170
CLAYTON GA
30525-4698
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-4485
  • Fax: 762-212-4368
Mailing address:
  • Phone: 706-613-4485
  • Fax: 762-212-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN264829
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11015334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: