1881923126 NPI number — GOOD SAMARITAN HEALTH CENTER OF COBB

Table of content: (NPI 1881923126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881923126 NPI number — GOOD SAMARITAN HEALTH CENTER OF COBB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD SAMARITAN HEALTH CENTER OF COBB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881923126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 ROBERTA DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30008-3855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-419-3120
Provider Business Mailing Address Fax Number:
770-419-3121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 ROBERTA DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30008-3855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-937-3850
Provider Business Practice Location Address Fax Number:
770-419-3121
Provider Enumeration Date:
12/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MATHISEN
Authorized Official First Name:
RORY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
251-751-2021

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  054389 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202G703251 . This is a "MEDICARE PART B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01000654 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08BBRXN . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003151808A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111043 . This is a "MEDICARE PART A PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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