Provider Demographics
NPI:1346420619
Name:BLUE RIDGE PSYCHIATRIC CONSULTANTS
Entity Type:Organization
Organization Name:BLUE RIDGE PSYCHIATRIC CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:GLADSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-258-2192
Mailing Address - Street 1:990 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4565
Mailing Address - Country:US
Mailing Address - Phone:706-258-2192
Mailing Address - Fax:706-258-2193
Practice Address - Street 1:990 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4565
Practice Address - Country:US
Practice Address - Phone:706-258-2192
Practice Address - Fax:706-258-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7043OtherMEDICARE GROUP NUMBER
GAS10294Medicare UPIN
GAF02887Medicare UPIN
GAGRP7043OtherMEDICARE GROUP NUMBER
GA26BDJXNMedicare PIN