Organization
GOOD SAMARITAN HEALTH CENTER OF COBB
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RORY MATHISEN MPH (DIRECTOR OF OPERATIONS)
(251) 751-2021
Entity
Organization
Contact information
Practice address
1605 ROBERTA DR SW, MARIETTA, GA 30008-3855
(404) 937-3850
(770) 419-3121
Mailing address
1605 ROBERTA DR SW, MARIETTA, GA 30008-3855
(770) 419-3120
(770) 419-3121
Taxonomy
Speciality
Code
Description
License number
State
251V00000X
Voluntary or Charitable Agency
054389
GA
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003151808A
—
GA
05
—
01000654
—
GA
01
—
08BBRXN
MEDICARE
GA
01
—
111043
MEDICARE PART A PTAN
GA
01
—
202G703251
MEDICARE PART B
—
Enumeration date
12/16/2009
Last updated
09/23/2022
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