Provider Demographics
NPI:1568524882
Name:METHODIST HOME OF THE SOUTH GA CONFERENCE
Entity Type:Organization
Organization Name:METHODIST HOME OF THE SOUTH GA CONFERENCE
Other - Org Name:METHODIST HOME FOR CHILDREN AND YOUTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUMFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-751-2800
Mailing Address - Street 1:304 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2422
Mailing Address - Country:US
Mailing Address - Phone:478-751-2800
Mailing Address - Fax:
Practice Address - Street 1:304 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2422
Practice Address - Country:US
Practice Address - Phone:478-751-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACI0000012147251S00000X
GACPA001036251S00000X
GACI0000011053251S00000X
GACCI11006251S00000X
GACI0000012098251S00000X
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00271679CMedicaid
GA00927671BMedicaid