Provider Demographics
NPI:1629207204
Name:MARK F BRECHTEL PHD PC
Entity Type:Organization
Organization Name:MARK F BRECHTEL PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRECHTEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-372-6199
Mailing Address - Street 1:428 SAWDUST TRL
Mailing Address - Street 2:
Mailing Address - City:NICHOLSON
Mailing Address - State:GA
Mailing Address - Zip Code:30565-3097
Mailing Address - Country:US
Mailing Address - Phone:706-372-6199
Mailing Address - Fax:
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:STE 103
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-369-0970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002805261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1932215845OtherCLINICIAN NPI
GA68BBGLBOtherMEDICARE B
GA750409758AMedicaid
GA1162893OtherCAQH
GAQ27113Medicare UPIN