Basic Information
| Provider Information | |||||||||
| NPI: | 1649455189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SLEEPMED INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 CHASTAIN CENTER BLVD NW | ||||||||
| Address2: | STE 66 | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301445598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 SECOND ST | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787455779 | ||||||||
| FaxNumber: | 4787427796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE & ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207RS0012X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7618325 | 01 | AETNA PPO | OTHER | 2860022 | 01 | AETNA HMO | OTHER |