Provider Demographics
NPI:1285937060
Name:GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.
Entity type:Organization
Organization Name:GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-787-9540
Mailing Address - Street 1:1112 RICKARD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1017
Mailing Address - Country:US
Mailing Address - Phone:217-787-9540
Mailing Address - Fax:217-787-9183
Practice Address - Street 1:1331 BEDFORD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1987
Practice Address - Country:US
Practice Address - Phone:321-622-8114
Practice Address - Fax:321-622-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00360786932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE18931Medicare UPIN