Provider Demographics
NPI:1558320572
Name:SOUTH GEORGIA NEUROPSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH GEORGIA NEUROPSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGICAL
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:229-439-8686
Mailing Address - Street 1:1211 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1935
Mailing Address - Country:US
Mailing Address - Phone:229-439-8686
Mailing Address - Fax:229-883-4484
Practice Address - Street 1:1211 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1935
Practice Address - Country:US
Practice Address - Phone:229-439-8686
Practice Address - Fax:229-883-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002280103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS01121Medicare UPIN
GA68BBFPPMedicare ID - Type Unspecified