MEDICARE: GEORGIA DEPARTMENT OF HUMAN RESOURCES

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	283Q00000X	Psychiatric Hospital	057-013	GA

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

General Provider Information

NPI Number	:	1285663385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DEPARTMENT OF HUMAN RESOURCES

Provider Business Mailing Address
First Line	:	705 NORTH DIVISION STREET NW
Second Line	:	BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
City	:	ROME
State	:	GA
Zip	:	30165-1454
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 NORTH DIVISION STREET NW
Second Line	:	BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
City	:	ROME
State	:	GA
Zip	:	30165-1454
Country	:	US
Telephone Number	:	706-295-6285
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	THOMAS MULLER
Credential	:	M.D.
Telephone Number	:	706-295-6285

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	09/22/2008

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Directions to “GEORGIA DEPARTMENT OF HUMAN RESOURCES ” Practice Location

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