Provider Demographics
NPI:1912030008
Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Entity Type:Organization
Organization Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Other - Org Name:MCRAE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KEITH
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 1:410 LAKESIDE DRIVE
Practice Address - Street 2:
Practice Address - City:MCRAE
Practice Address - State:GA
Practice Address - Zip Code:31055
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:2007-03-14
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606284LMedicaid
GA300030912AMedicaid
GAGRP2130Medicare UPIN