Provider Demographics
NPI:1598855355
Name:PSYCHIATRIC GROUP OF THE COASTAL EMPIRE, INC.
Entity Type:Organization
Organization Name:PSYCHIATRIC GROUP OF THE COASTAL EMPIRE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:PO BOX 931979
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1968
Mailing Address - Country:US
Mailing Address - Phone:912-350-4905
Mailing Address - Fax:912-350-4955
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-4905
Practice Address - Fax:912-350-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3000032168AMedicaid
GAGRP2533Medicare PIN
GACD1515Medicare PIN
SCGRP7416Medicare PIN