MEDICARE: PSYCHIATRIC SERVICES AT BROOKSTONE, PC

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	2084P0800X	Psychiatry Physician	65152	GA

General Provider Information

NPI Number	:	1194129544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRIC SERVICES AT BROOKSTONE, PC

Provider Business Mailing Address
First Line	:	2263 BROOKSTONE CENTRE PKWY STE C
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-4650
Country	:	US
Telephone Number	:	706-341-4060
Fax Number	:	706-341-4061

Provider Business Practice Location Address
First Line	:	2263 BROOKSTONE CENTRE PKWY STE C
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-4650
Country	:	US
Telephone Number	:	706-341-4060
Fax Number	:	706-341-4061

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN MCPHERSON
Credential	:	MD
Telephone Number	:	706-341-4060

Provider Enumeration Date	:	10/14/2014
Last Update Date	:	10/14/2014

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