Provider Demographics
NPI:1710972773
Name:FAYETTE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:FAYETTE COUNTY BOARD OF HEALTH
Other - Org Name:FAYETTE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-298-7732
Mailing Address - Street 1:140 STONEWALL AVE W
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1520
Mailing Address - Country:US
Mailing Address - Phone:770-461-1178
Mailing Address - Fax:770-460-2457
Practice Address - Street 1:140 STONEWALL AVE W
Practice Address - Street 2:SUITE 107
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1520
Practice Address - Country:US
Practice Address - Phone:770-305-5416
Practice Address - Fax:770-305-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000456453EMedicaid
GA000784352CMedicaid
GA000052093EMedicaid
GA000784352AMedicaid
GA000456453WMedicaid