Provider Demographics
NPI:1013034552
Name:PEACH STATE HEALTH PLAN, INC
Entity Type:Organization
Organization Name:PEACH STATE HEALTH PLAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:678-556-2461
Mailing Address - Street 1:3200 HIGHLANDS PKWY SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5166
Mailing Address - Country:US
Mailing Address - Phone:678-556-2300
Mailing Address - Fax:770-803-0043
Practice Address - Street 1:3200 HIGHLANDS PKWY SE
Practice Address - Street 2:SUITE 300
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5166
Practice Address - Country:US
Practice Address - Phone:678-556-2300
Practice Address - Fax:770-803-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12315302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization