Basic Information
Provider Information | |||||||||
NPI: | 1689657637 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY MENTAL HEALTH CENTER OF MIDDLE GEORGIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2121A BELLEVUE RD | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310212998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782721190 | ||||||||
FaxNumber: | 4782747628 | ||||||||
Practice Location | |||||||||
Address1: | 2121A BELLEVUE RD | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310212998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782721190 | ||||||||
FaxNumber: | 4782747628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2005 | ||||||||
LastUpdateDate: | 01/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORAN | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4782721190 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 007-R-0003 | GA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 300030912A | 05 | GA |   | MEDICAID | 000606284H | 05 | GA |   | MEDICAID |