Basic Information
| Provider Information | |||||||||
| NPI: | 1326191180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN LAKES MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 162 LEGACY PT | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305255354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067823100 | ||||||||
| FaxNumber: | 7067826897 | ||||||||
| Practice Location | |||||||||
| Address1: | 162 LEGACY PT | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305255354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067820401 | ||||||||
| FaxNumber: | 7067820451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7067820408 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 119-621 | GA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 293932 | 01 | GA | WELLCARE | OTHER | 51000340 | 01 | GA | BLUE CROSS OF GEORGIA | OTHER | 00001559A | 05 | GA | MEDICAID | 0001559S | 05 | GA | MEDICAID | 10063437 | 01 | GA | AMERIGROUP | OTHER |