1366450934 NPI number — PEACH COUNTY BOARD OF HEALTH

Table of content: (NPI 1366450934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366450934 NPI number — PEACH COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACH COUNTY BOARD OF HEALTH
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:
PEACH COUNTY HEALTH DEPARTMENT
Provider Other Organization Name Type Code:
5
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:
1366450934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 2ND ST STE 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-6328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-297-5190
Provider Business Mailing Address Fax Number:
478-751-6099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 BLUEBIRD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT VALLEY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31030-5096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-825-6939
Provider Business Practice Location Address Fax Number:
478-825-6792
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAFT
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
DISTRICT HEALTH DIRECTOR
Authorized Official Telephone Number:
478-751-6303

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00051961K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000733224A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003185983A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003186608A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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