Provider Demographics
NPI:1306116637
Name:EVERGREEN GERIATRIC CARE MANAGEMENT, LLC
Entity type:Organization
Organization Name:EVERGREEN GERIATRIC CARE MANAGEMENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:EVE
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, C-ASWCM
Authorized Official - Phone:706-288-5428
Mailing Address - Street 1:1521 STOVALL ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6215
Mailing Address - Country:US
Mailing Address - Phone:706-288-5428
Mailing Address - Fax:
Practice Address - Street 1:1521 STOVALL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6215
Practice Address - Country:US
Practice Address - Phone:706-288-5428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW004126305R00000X, 305S00000X, 302F00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I801953Medicare UPIN