Basic Information
| Provider Information | |||||||||
| NPI: | 1174512966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER EDGE BEHAVIORAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787514519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787514519 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4787523231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000604194E | 05 | GA | MEDICAID |