CARROLL COUNTY NEUROLOGY

Provider Demographics

• NPI: 1407916455
• Name: CARROLL COUNTY NEUROLOGY
• Entity Type: Organization
• Organization Name: CARROLL COUNTY NEUROLOGY
• Other - Org Name: WEST GEORGIA SLEEP DISORDERS AND NEUROLOGY ASSOCIATES
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: ADMINISTRATOR
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: REBECCA
• Authorized Official - Middle Name: LEE
• Authorized Official - Last Name: WALKER
• Authorized Official - Phone: 770-832-2775
• Mailing Address - Street 1: 524 DIXIE ST
• Mailing Address - City: CARROLLTON
• Mailing Address - State: GA
• Mailing Address - Zip Code: 30117-3805
• Mailing Address - Country: US
• Mailing Address - Phone: 770-832-2775
• Mailing Address - Fax: 770-832-9529
• Practice Address - Street 1: 524 DIXIE ST
• Practice Address - City: CARROLLTON
• Practice Address - State: GA
• Practice Address - Zip Code: 30117-3805
• Practice Address - Country: US
• Practice Address - Phone: 770-832-2775
• Practice Address - Fax: 770-832-9529
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-12-11
• Last Update Date: 2009-12-03

Provider Licenses

State	License ID	Taxonomies
GA	040159	2084N0400X
GA	050478	2084N0400X
GA	053520	2084N0400X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	2084N0400X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Neurology	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	130011906	Other	R X R MEDICARE
	13BDDKV01	Other	MEDICARE ID
GA	000920796B	Medicaid
AL	009981360	Medicaid
	130024279	Other	R X R MEDICARE
AL	009602420	Medicaid
	13BDDKV	Other	MEDICARE
	52212528	Other	BCBS
	864345	Other	BCBS
GA	000670909E	Medicaid
	13BDCK01	Other	MEDICARE ID
	13BDCKS	Other	MEDICARE ID
	506390	Other	BSBC
GA	586993320E	Medicaid
GA	000920796A	Medicaid
	5632868	Other	CIGNA
GA	000920796C	Medicaid
	13BDFFB01	Other	MEDICARE ID
	6941783	Other	CIGNA
	7357225	Other	AETNA
GA	000670909A	Medicaid
GA	000670909F	Medicaid
	13BDFFB	Other	MEDICARE ID
GA	000670909F	Medicaid
GA	000920796A	Medicaid