Provider Demographics
NPI:1285663385
Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Entity Type:Organization
Organization Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Other - Org Name:NORTHWEST GEORGIA REGIONAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-295-6285
Mailing Address - Street 1:705 NORTH DIVISION STREET NW
Mailing Address - Street 2:BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 NORTH DIVISION STREET NW
Practice Address - Street 2:BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1454
Practice Address - Country:US
Practice Address - Phone:706-295-6285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-01
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057-013283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000142172AMedicaid
GA112002GAMedicare ID - Type UnspecifiedMEDICARE B
GA000142172AMedicaid