Provider Demographics
NPI:1649201625
Name:INTEGRATED BEHAVIORAL CENTER PC
Entity type:Organization
Organization Name:INTEGRATED BEHAVIORAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:K
Authorized Official - Last Name:DASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-355-4987
Mailing Address - Street 1:1121 CORNELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406
Mailing Address - Country:US
Mailing Address - Phone:912-355-4987
Mailing Address - Fax:912-353-7257
Practice Address - Street 1:1121 CORNELL AVENUE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-355-4987
Practice Address - Fax:912-353-7257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002990104100000X
GA225362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00235034AMedicaid
D29243Medicare UPIN