Provider Demographics
NPI:1477265718
Name:GEODE HEALTH OF GEORGIA LLC
Entity Type:Organization
Organization Name:GEODE HEALTH OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-686-2706
Mailing Address - Street 1:1211 W 22ND ST STE 406
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2169
Mailing Address - Country:US
Mailing Address - Phone:888-902-1704
Mailing Address - Fax:302-907-3568
Practice Address - Street 1:227 SCENIC HWY STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5649
Practice Address - Country:US
Practice Address - Phone:630-912-4241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty