Provider Demographics
NPI:1922230648
Name:PEACHSTATE PSYCHIATRIC SERVICES, INC.
Entity Type:Organization
Organization Name:PEACHSTATE PSYCHIATRIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:A
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-575-4785
Mailing Address - Street 1:1720 PEACHTREE ST NW STE 640
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2450
Mailing Address - Country:US
Mailing Address - Phone:404-575-4785
Mailing Address - Fax:
Practice Address - Street 1:1720 PEACHTREE ST NW STE 640
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2450
Practice Address - Country:US
Practice Address - Phone:404-575-4785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080408LGB273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
162363OtherVALUE OPTIONS
GACLARENCE5Medicaid
GA52806851OtherBC/BS GEORGIA
102379467OtherUBH/EVERCARE
713313717OtherAMERIGROUP
278688000OtherMAGELLAN PERSONAL
GA7698253OtherAETNA
GA80440600OtherMAGELLAN GROUP
158479400OtherOWCP
26BDHBDOtherWELLCARE MEDICARE
27868800OtherWELLCRE MEDICAID
000851309AOtherMEDICAID GBH
52806851OtherBC/BS PLAN LOCATOR