MEDICARE: BULLOCH COUNTY BOARD OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043243876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BULLOCH COUNTY BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	3 W ALTMAN ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5212
Country	:	US
Telephone Number	:	912-764-2402
Fax Number	:	912-764-5561

Provider Business Practice Location Address
First Line	:	3 W ALTMAN ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5212
Country	:	US
Telephone Number	:	912-764-2402
Fax Number	:	912-764-5561

Authorized Official
Title or Position	:	PSO
Name	:	STARLA SUTTON
Credential	:
Telephone Number	:	91233885263

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	04/19/2012

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