Provider Demographics
NPI:1912131319
Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Entity type:Organization
Organization Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-568-5207
Mailing Address - Street 1:3000 SCHATULGA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-3117
Mailing Address - Country:US
Mailing Address - Phone:706-568-5207
Mailing Address - Fax:
Practice Address - Street 1:3000 SCHATULGA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-3117
Practice Address - Country:US
Practice Address - Phone:706-568-5207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPERMIT # 106-291283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA106-291OtherSTATE PERMIT #
GA114013Medicare Oscar/Certification