1992036909 NPI number — DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES

Table of content: (NPI 1992036909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992036909 NPI number — DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
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:
EAST CENTRAL REGIONAL HOSPITAL
Provider Other Organization Name Type Code:
3
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:
1992036909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MYRTLE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRACEWOOD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30812-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-790-2030
Provider Business Mailing Address Fax Number:
706-790-2025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MYRTLE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRACEWOOD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30812-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-790-2496
Provider Business Practice Location Address Fax Number:
706-790-2340
Provider Enumeration Date:
01/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official Telephone Number:
706-790-2030

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  PHH004147 , 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: 1110395 . This is a "NCPDP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000355737A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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