1124565650 NPI number — GEORGIA HIGHLANDS MEDICAL SERVICES, INC

Table of content: (NPI 1124565650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124565650 NPI number — GEORGIA HIGHLANDS MEDICAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA HIGHLANDS MEDICAL SERVICES, INC
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:
6
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:
1124565650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30028-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-887-1668
Provider Business Mailing Address Fax Number:
770-781-9937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5959 HIGHWAY 53 E
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DAWSONVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30534-9511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-887-1668
Provider Business Practice Location Address Fax Number:
770-781-9937
Provider Enumeration Date:
01/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHIFFLET
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
770-887-1668

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003188430A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300022400A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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