| Organization Name: | PEACH STATE HEALTH PLAN, INC |
| NPI Number: | 1013034552 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | HERBERT SPENCER (COMPLIANCE OFFICER) |
| Mailing Address: | 3200 Highlands Pkwy Se Suite 300 Smyrna |
| State: | GA US |
| Postal Code: | 300825166 |
| Phone Number: | 6785562300 |
| Fax Number: | 7708030043 |
| NPI Enumeration Date: | 03/22/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 302R00000X |
| License Number: | 12315 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Managed Care Organizations |
| Taxonomy Classification: | Health Maintenance Organization |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A form of health insurance in which its members prepay a premium for the HMO |