Provider Demographics
NPI:1679634612
Name:PROVIDENT HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:PROVIDENT HEALTH SERVICES, INC.
Other - Org Name:CLINICAL GENETICS ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
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 933213
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3213
Mailing Address - Country:US
Mailing Address - Phone:912-350-8490
Mailing Address - Fax:912-350-8199
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:912-350-8490
Practice Address - Fax:912-350-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular GeneticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDF7661OtherRR MEDICARE
GAGRP5064Medicare PIN