Basic Information
| Provider Information | |||||||||
| NPI: | 1821555913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
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| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 MORGAN CREEK DR | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783747037 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2019 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4782756811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000643618C | 05 | GA | MEDICAID |