Provider Demographics
NPI:1689657637
Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Entity Type:Organization
Organization Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Other - Org Name:COMMUNITY MENTAL HEALTH CENTER OF MIDDLE GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-272-1190
Mailing Address - Street 1:2121A BELLEVUE RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2998
Mailing Address - Country:US
Mailing Address - Phone:478-272-1190
Mailing Address - Fax:478-274-7628
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-274-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007-R-0003261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030912AMedicaid
GA000606284HMedicaid
GA300030912AMedicaid
GAGRP2130Medicare PIN