Organization
PROVIDENT HEALTH SERVICES, INC.
Active
Other names
Clinical Genetics Associates
Organization subpart
No
Provider details
NPI number
Authorized official
ROBIN J. MADDOX (PROVIDER ENROLLMENT COORDINATOR)
(912) 350-9335
Entity
Organization
Contact information
Practice address
4700 WATERS AVE, SAVANNAH, GA 31404-6220
(912) 350-8490
(912) 350-8199
Mailing address
PO BOX 933213, ATLANTA, GA 31193-3213
(912) 350-8490
(912) 350-8199
Taxonomy
Speciality
Code
Description
License number
State
207SG0201X
Clinical Genetics (M.D.) Physician
Primary
—
—
207SG0203X
Clinical Molecular Genetics Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DF7661
RR MEDICARE
SC
Enumeration date
12/13/2006
Last updated
11/12/2007
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