Provider Demographics
NPI:1922036508
Name:PROMEDICA, INC.
Entity Type:Organization
Organization Name:PROMEDICA, INC.
Other - Org Name:PROMEDICA PSYCHIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:LITTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, APRN, BC
Authorized Official - Phone:770-554-8812
Mailing Address - Street 1:2430 TUCKER DR
Mailing Address - Street 2:BLDG A
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4390
Mailing Address - Country:US
Mailing Address - Phone:770-554-8812
Mailing Address - Fax:770-554-9810
Practice Address - Street 1:2430 TUCKER DR
Practice Address - Street 2:BLDG A
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4390
Practice Address - Country:US
Practice Address - Phone:770-554-8812
Practice Address - Fax:770-554-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00345408AMedicaid
GA00345408AMedicaid
GA89BBBBHMedicare PIN
GA511I890007Medicare PIN
GA26BDFRZMedicare PIN
GAD40269Medicare UPIN
GA89BBBLLMedicare PIN
GAGRP2921Medicare PIN