Provider Demographics
NPI:1740372473
Name:PALMETTO HEALTH COUNCIL INC
Entity type:Organization
Organization Name:PALMETTO HEALTH COUNCIL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WOLLENZIEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DBA
Authorized Official - Phone:404-929-8824
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:643 MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1138
Practice Address - Country:US
Practice Address - Phone:404-929-8824
Practice Address - Fax:404-929-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAH800040207Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000228379AMedicaid
GA000472128FMedicaid
GA931512872AMedicaid
GA000472128AMedicaid
GA000472128GMedicaid
GA000472128EMedicaid
GA000472128HMedicaid
GA111924Medicare PIN
GA000472128HMedicaid
GA000472128EMedicaid
GA111819Medicare ID - Type Unspecified
GA931512872AMedicaid
GA111903Medicare PIN
GA111818Medicare ID - Type Unspecified