Provider Demographics
NPI:1417042391
Name:GORDON COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:GORDON COUNTY BOARD OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-624-1444
Mailing Address - Street 1:310 N RIVER ST NW
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-9408
Mailing Address - Country:US
Mailing Address - Phone:706-624-1444
Mailing Address - Fax:706-624-1450
Practice Address - Street 1:310 N RIVER ST NW
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-9408
Practice Address - Country:US
Practice Address - Phone:706-624-1444
Practice Address - Fax:706-624-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025271251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10076442OtherAMERIGROUP, CMO
GA140294OtherPEACH STATE, CMO
GA340939OtherWELLCARE, CMO
GA340939OtherWELLCARE, CMO