Healthcare Provider Details

I. General information

NPI: 1679634612
Provider Name (Legal Business Name): PROVIDENT HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

PO BOX 933213
ATLANTA GA
31193-3213
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-8490
  • Fax: 912-350-8199
Mailing address:
  • Phone: 912-350-8490
  • Fax: 912-350-8199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBIN J. MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335