NPIMap

Organization Active NPI

Professional Resource Management of Wiregrass, LLC

Doing business as Southeast Psychiatric Services

  • Psychiatry Physician
  • Dothan, AL
National Provider Identifier
1033495221
Registry record updated Dec 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PROFESSIONAL RESOURCE MANAGEMENT OF WIREGRASS, LLC
Doing business as
Southeast Psychiatric Services
Practice address
2812 Hartford Hwy Ste 1
Dothan, AL 36305-4927
Phone
(334) 712-1170
Fax
(334) 460-8391
NPI assigned
Nov 1, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nancy A Gilley
Title
Authorized Official
Phone
(334) 712-1170

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

2812 Hartford Hwy Ste 1
Dothan, AL 36305-4927

Mailing address

2812 Hartford Hwy Ste 1
Dothan, AL 36305-4927
Phone (334) 712-1170

Other identifiers 1

IdentifierTypeStateIssuer
134225MedicaidAL

Other names 1

  • SOUTHEAST PSYCHIATRIC SERVICES Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050428001294 AL Part B Supplier - Clinic/Group Practice 5698714525 Receives reassigned benefits from 14 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Dothan, AL; Ozark, AL

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1320105600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608595200000",
    "number": "1033495221",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2812 HARTFORD HWY STE 1",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363054927",
            "telephone_number": "334-712-1170",
            "fax_number": "334-460-8391"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2812 HARTFORD HWY STE 1",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363054927",
            "telephone_number": "334-712-1170",
            "fax_number": "334-460-8391"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL RESOURCE MANAGEMENT OF WIREGRASS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-01",
        "last_updated": "2020-12-22",
        "certification_date": "2020-12-22",
        "status": "A",
        "authorized_official_last_name": "GILLEY",
        "authorized_official_first_name": "NANCY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "334-712-1170"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "134225",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTHEAST PSYCHIATRIC SERVICES",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "SOUTHEAST PSYCHIATRIC SERVICES",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dothan, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.