Provider Demographics
NPI:1205031267
Name:NORTHEAST HEALTH DISTRICT - EPSDT
Entity Type:Organization
Organization Name:NORTHEAST HEALTH DISTRICT - EPSDT
Other - Org Name:MORGAN CO HLTH DEPT DIST 10
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOGGANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-583-2870
Mailing Address - Street 1:2005 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-2055
Mailing Address - Country:US
Mailing Address - Phone:706-752-1266
Mailing Address - Fax:706-752-0286
Practice Address - Street 1:2005 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2055
Practice Address - Country:US
Practice Address - Phone:706-752-1266
Practice Address - Fax:706-752-0286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST HEALTH DISTRICT - EPSDT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-19
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000051983HMedicaid