| Greater Image Healthcare, Corp | |
|
401 Roberson Street Fayetteville NC 28301-5423 | |
| (910) 321-0069 | |
| (910) 491-1000 |
| Full Name | Greater Image Healthcare, Corp |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 401 Roberson Street, Fayetteville, North Carolina |
| Authorized Official Name and Position | Rodney Johnson (CEO) |
| Authorized Official Contact | 9103210069 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Greater Image Healthcare, Corp 401 Roberson Street Fayetteville NC 28301-5423 Ph: (910) 321-0069 | Greater Image Healthcare, Corp 401 Roberson Street Fayetteville NC 28301-5423 Ph: (910) 321-0069 |
| NPI Number | 1255574034 |
|---|---|
| Provider Enumeration Date | 04/09/2009 |
| Last Update Date | 07/15/2020 |
| Certification Date | 07/15/2020 |
| Medicare PECOS PAC ID | 1052647328 |
|---|---|
| Medicare Enrollment ID | O20190724001344 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255574034 | NPI | - | NPPES |
| 1457481988 | Medicaid | NC | |
| 8302847 | Medicaid | NC | |
| 1508996059 | Medicaid | NC | |
| 5919267 | Medicaid | NC | |
| 6008694 | Medicaid | NC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| 315P00000X | Intermediate Care Facility, Intellectual Disabilities | (* (Not Available)) | Secondary |
| Provider Name | H Wayne Tobin |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1477619856 PECOS PAC ID: 0143282285 Enrollment ID: I20041101000290 |
| Provider Name | Donald J Jackson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1942577200 PECOS PAC ID: 4284873704 Enrollment ID: I20130613000332 |
| Provider Name | James Parker |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1215320700 PECOS PAC ID: 9739415001 Enrollment ID: I20190724001534 |
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