Basic Information
| Provider Information | |||||||||
| NPI: | 1093784720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE FLINT AREA COMMUNITY SERVICE BOARD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIDDLE FLINT BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UTILIZATION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2298155286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 000607087D | 05 | GA | MEDICAID | 000604502B | 05 | GA | MEDICAID | 000603237K | 05 | GA | MEDICAID | 000604502A | 05 | GA | MEDICAID | 000603237B | 05 | GA | MEDICAID | 000607087H | 05 | GA | MEDICAID | 000603237A | 05 | GA | MEDICAID | 000603237H | 05 | GA | MEDICAID | 000607087L | 05 | GA | MEDICAID | 000921335B | 05 | GA | MEDICAID | 000603237F | 05 | GA | MEDICAID | 000607087A | 05 | GA | MEDICAID | 000607087E | 05 | GA | MEDICAID | 000603237D | 05 | GA | MEDICAID | 000603237J | 05 | GA | MEDICAID | 000603237M | 05 | GA | MEDICAID | 000603237P | 05 | GA | MEDICAID | 000607087G | 05 | GA | MEDICAID | 000701126B | 05 | GA | MEDICAID | 000701126C | 05 | GA | MEDICAID | 000921335C | 05 | GA | MEDICAID |