Basic Information
| Provider Information | |||||||||
| NPI: | 1346418068 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE FLINT COMMUNITY SERVICE BOARD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDDLE FLINT BEAHVIORAL HEALTHCARE ITR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | P.O. DRAWER 1348 | ||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 BRANNAN AVE | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317094012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UTILIZATION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2298155286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDDLE FLINT AREA COMMUNITY SERVICE BOARD | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000921335C | 05 | GA | MEDICAID |