Provider Demographics
NPI:1508134156
Name:EDUCATION SYSTEM MANAGEMENT, INC
Entity Type:Organization
Organization Name:EDUCATION SYSTEM MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MBA
Authorized Official - Phone:770-892-5284
Mailing Address - Street 1:1115 MOUNT ZION RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2266
Mailing Address - Country:US
Mailing Address - Phone:770-742-0265
Mailing Address - Fax:770-742-0862
Practice Address - Street 1:125 HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:770-742-0265
Practice Address - Fax:770-742-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0037271041C0700X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148586AMedicaid
GA003168151AMedicaid