Provider Demographics
NPI:1821099474
Name:DEKALB MEDICAL PSYCH UNIT
Entity Type:Organization
Organization Name:DEKALB MEDICAL PSYCH UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAUNT-SAMFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-686-4918
Mailing Address - Street 1:2701 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5918
Mailing Address - Country:US
Mailing Address - Phone:404-501-1000
Mailing Address - Fax:404-501-5811
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-5185
Practice Address - Fax:404-501-5811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEKALB MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-04
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044039273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11S076Medicare Oscar/Certification