1023253408 NPI number — TATTNALL HOSPITAL COMPANY LLC

Table of content: (NPI 1023253408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023253408 NPI number — TATTNALL HOSPITAL COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TATTNALL HOSPITAL COMPANY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTIM PRIMARY CARE - COBBTOWN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023253408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 E DERENNE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-6736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-644-5300
Provider Business Mailing Address Fax Number:
912-644-5260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36671 HWY 23
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COBBTOWN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30420-6042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-557-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GUENTHNER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY OF COMM.HOSP.HOLD.CO., LL
Authorized Official Telephone Number:
312-627-8427

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  038774 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 925639844B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118512 . This is a "MEDICARE PART A" identifier . This identifiers is of the category "OTHER".




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