1386664779 NPI number — WELLSTAR SYLVAN GROVE HOSPITAL, INC

Table of content: (NPI 1386664779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386664779 NPI number — WELLSTAR SYLVAN GROVE HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSTAR SYLVAN GROVE 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:
SYLVAN GROVE HOSPITAL
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:
1386664779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 PARKWAY PL SE STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30067-8237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-956-4981
Provider Business Mailing Address Fax Number:
770-999-2489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 MCDONOUGH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30233-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-775-7861
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUZDINSKI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EVP
Authorized Official Telephone Number:
470-644-0012

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00001856A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00791062E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00885024B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010492809(TRR) , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00282488B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00495382D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 416159 . This is a "COVENTRY HEALTH CARE GEOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 973964590 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00214607F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 085001319G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004378 . This is a "BCBS OF GEORGIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 152710726 . This is a "KAISER FOUNDATION HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1703761 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23360 . This is a "COVENTRY HEALTH CARE GEOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00211549E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000444 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111319B000000 . This is a "SECTION 1011" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00001856S , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00715107T , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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