Provider Demographics
NPI:1689096828
Name:AMERICAN BRAIN, LLC
Entity Type:Organization
Organization Name:AMERICAN BRAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADEREMI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOSUNMU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-877-9111
Mailing Address - Street 1:938 ELMA G MILES PKWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4515
Mailing Address - Country:US
Mailing Address - Phone:912-877-9111
Mailing Address - Fax:912-877-5437
Practice Address - Street 1:938 ELMA G MILES PKWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4515
Practice Address - Country:US
Practice Address - Phone:912-877-9111
Practice Address - Fax:912-877-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047893305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA802238916AMedicaid