Provider Demographics
NPI:1912003401
Name:GEORGIA NEUROLOGY AND REHAB
Entity Type:Organization
Organization Name:GEORGIA NEUROLOGY AND REHAB
Other - Org Name:COASTAL NEUROLOGICAL INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHENKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-265-1357
Mailing Address - Street 1:1111 GLYNCO PARKWAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:912-265-1357
Mailing Address - Fax:912-265-0495
Practice Address - Street 1:1111 GLYNCO PARKWAY
Practice Address - Street 2:SUITE 400
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525
Practice Address - Country:US
Practice Address - Phone:912-265-1357
Practice Address - Fax:912-265-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
GA036000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC7432OtherRAILROAD MEDICARE PIN
GA000516942HMedicaid
GADC7432OtherRAILROAD MEDICARE PIN
GAGRP6703Medicare PIN