Basic Information
| Provider Information | |||||||||
| NPI: | 1144401787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARECONNECT HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARECONNECT FAMILY PRACTICE AND PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 5610 | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310101514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292738881 | ||||||||
| FaxNumber: | 2292738985 | ||||||||
| Practice Location | |||||||||
| Address1: | 636 2ND AVENUE, SW | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310792046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293652570 | ||||||||
| FaxNumber: | 2293652571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2292738881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 654828836A | 05 | GA | MEDICAID |