Provider Demographics
NPI:1881923126
Name:GOOD SAMARITAN HEALTH CENTER OF COBB
Entity type:Organization
Organization Name:GOOD SAMARITAN HEALTH CENTER OF COBB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:251-751-2021
Mailing Address - Street 1:1605 ROBERTA DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-3855
Mailing Address - Country:US
Mailing Address - Phone:770-419-3120
Mailing Address - Fax:770-419-3121
Practice Address - Street 1:1605 ROBERTA DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-3855
Practice Address - Country:US
Practice Address - Phone:404-937-3850
Practice Address - Fax:770-419-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054389251V00000X
GA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G703251OtherMEDICARE PART B
GA01000654Medicaid
GA08BBRXNOtherMEDICARE
GA003151808AMedicaid
GA111043OtherMEDICARE PART A PTAN