Healthcare Provider Details

I. General information

NPI: 1336843499
Provider Name (Legal Business Name): EVOLVE MANAGED CARE SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 BLACKBURN DR STE 523
AUGUSTA GA
30907-8202
US

IV. Provider business mailing address

519 BLACKBURN DR STE 523
AUGUSTA GA
30907-8202
US

V. Phone/Fax

Practice location:
  • Phone: 912-297-0066
  • Fax:
Mailing address:
  • Phone: 912-297-0066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA W MCFANN
Title or Position: COO
Credential:
Phone: 912-297-0066