Provider Demographics
NPI:1780814574
Name:SAINT LAZARUS BEHAVIORAL HEALTH INC.
Entity Type:Organization
Organization Name:SAINT LAZARUS BEHAVIORAL HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:INIMBOM
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-765-8224
Mailing Address - Street 1:273 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-7565
Mailing Address - Country:US
Mailing Address - Phone:865-765-8224
Mailing Address - Fax:478-474-6585
Practice Address - Street 1:4905 FORSYTH RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4401
Practice Address - Country:US
Practice Address - Phone:865-765-8224
Practice Address - Fax:478-474-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056360261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA712889273AMedicaid
TN148899Medicare UPIN