Provider Demographics
NPI:1467091629
Name:DR. CORETTA D. GERVIN HEALTHCARE
Entity Type:Organization
Organization Name:DR. CORETTA D. GERVIN HEALTHCARE
Other - Org Name:CDG HEALTHCARE PROVIDER, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CORETTA
Authorized Official - Middle Name:DELIA
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:404-710-6646
Mailing Address - Street 1:414 N WESTOVER BLVD STE D1
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2102
Mailing Address - Country:US
Mailing Address - Phone:404-710-6466
Mailing Address - Fax:229-389-2573
Practice Address - Street 1:414 N WESTOVER BLVD STE D1
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2102
Practice Address - Country:US
Practice Address - Phone:404-710-6646
Practice Address - Fax:229-234-1391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDG HEALTHCARE PROVIDER, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-04
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003239804AMedicaid
GA003239804BMedicaid