Provider Demographics
NPI:1124331970
Name:ALBANY ADDICTION ASSOCIATES, INC. D/B/A PRIVATE CLINIC ALBANY
Entity type:Organization
Organization Name:ALBANY ADDICTION ASSOCIATES, INC. D/B/A PRIVATE CLINIC ALBANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:229-903-0022
Mailing Address - Street 1:2607 LEDO RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1211
Mailing Address - Country:US
Mailing Address - Phone:229-903-0022
Mailing Address - Fax:229-903-0025
Practice Address - Street 1:2607 LEDO RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1211
Practice Address - Country:US
Practice Address - Phone:229-903-0022
Practice Address - Fax:229-903-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANTP0010252084A0401X
GAPHOP0000261835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty