Provider Demographics
NPI:1508039306
Name:AFFILIATED BEHAVIORAL MEDICAL GROUP
Entity Type:Organization
Organization Name:AFFILIATED BEHAVIORAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AFFILIATED BEHAVIORAL MEDICAL OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-784-2782
Mailing Address - Street 1:1014 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2944
Mailing Address - Country:US
Mailing Address - Phone:404-784-2782
Mailing Address - Fax:
Practice Address - Street 1:1014 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2944
Practice Address - Country:US
Practice Address - Phone:404-784-2782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASMC2007-021261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G260002Medicare PIN