Basic Information
| Provider Information | |||||||||
| NPI: | 1144224767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGIA DEPARTMENT OF HUMAN RESOURCES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST CENTRAL GEORGIA REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 SCHATULGA RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319073117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
| FaxNumber: | 7065685339 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 SCHATULGA RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319073117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
| FaxNumber: | 7065685339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADERIBIGBE | ||||||||
| AuthorizedOfficialFirstName: | YEKEEN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7065685209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | A-106-291 | GA | Y | Hospitals | Psychiatric Hospital |
No ID Information.