MEDICARE: ELIZABETH BRIDGEWATER

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1922508704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BRIDGEWATER

Provider Business Mailing Address
First Line	:	5020 MERLIN DR
Second Line	:
City	:	OAKWOOD
State	:	GA
Zip	:	30566-2623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	906 INTERSTATE RIDGE DR STE C
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-7074
Country	:	US
Telephone Number	:	404-934-8338
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2018
Last Update Date	:	02/18/2018

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