1114014669 NPI number — JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114014669 NPI number — JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
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:
COOLIDGE PRIMARY CARE CLINIC
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:
1114014669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 CAIRO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31792-4255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-228-8800
Provider Business Mailing Address Fax Number:
229-228-8892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1034 SOUTH PINE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOLIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-346-3511
Provider Business Practice Location Address Fax Number:
229-346-3512
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HIGHTOWER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
229-228-2853

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  136-91 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000063F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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