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NPI Code Detail

MEDICARE: GOOD SAMARITAN HEALTH CENTER OF COBB

MEDICARE: GOOD SAMARITAN HEALTH CENTER OF COBB
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
1251V00000XVoluntary or Charitable Agency054389GA
2261QF0400XFederally Qualified Health Center (FQHC)GA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1202G703251OTHERMEDICARE PART B
308BBRXNOTHERGAMEDICARE
5111043OTHERGAMEDICARE PART A PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1881923126
Entity Type Code : Organization
Provider Name (Legal Business Name) : GOOD SAMARITAN HEALTH CENTER OF COBB
Provider Business Mailing Address
First Line : 1605 ROBERTA DR SW
Second Line :
City : MARIETTA
State : GA
Zip : 30008-3855
Country : US
Telephone Number : 770-419-3120
Fax Number : 770-419-3121
Provider Business Practice Location Address
First Line : 1605 ROBERTA DR SW
Second Line :
City : MARIETTA
State : GA
Zip : 30008-3855
Country : US
Telephone Number : 404-937-3850
Fax Number : 770-419-3121
Authorized Official
Title or Position : DIRECTOR OF OPERATIONS
Name : MR. RORY MATHISEN
Credential : MPH
Telephone Number : 251-751-2021
Provider Enumeration Date : 12/16/2009
Last Update Date : 09/23/2022

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1609160266 — KATHERINE M FIELD PHARMD
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1659650331 — ALAN B KIRK PHD, LCSW
Practice Location Address:
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30008-3855
Practice Phone: 770-419-3120
Practice Fax: 770-419-3121

Directions to “GOOD SAMARITAN HEALTH CENTER OF COBB ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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