Provider Demographics
NPI:1053391581
Name:DOTHAN PSYCHIATRIC, PC
Entity type:Organization
Organization Name:DOTHAN PSYCHIATRIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GISELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-702-8425
Mailing Address - Street 1:256 HONEYSUCKLE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1157
Mailing Address - Country:US
Mailing Address - Phone:334-702-8425
Mailing Address - Fax:334-794-8460
Practice Address - Street 1:256 HONEYSUCKLE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1157
Practice Address - Country:US
Practice Address - Phone:334-702-8425
Practice Address - Fax:334-794-8460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907650Medicaid
AL529907650Medicaid
DG5936Medicare PIN
AL=========OtherTRICARE GROUP PROVIDER #