Basic Information
| Provider Information | |||||||||
| NPI: | 1467576140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBUS SPEECH & HEARING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2424 DOUBLE CHURCHES RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319092741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063246112 | ||||||||
| FaxNumber: | 7065968259 | ||||||||
| Practice Location | |||||||||
| Address1: | 2424 DOUBLE CHURCHES RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319092741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063246112 | ||||||||
| FaxNumber: | 7065968259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 08/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | GLOVER | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7063246112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 062134 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 235Z00000X | 062134 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000636171A | 05 | GA | MEDICAID |