1922211515 NPI number — HOSPITAL AUTHORITY OF MITCHELL COUNTY

Table of content: (NPI 1922211515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922211515 NPI number — HOSPITAL AUTHORITY OF MITCHELL COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOSPITAL AUTHORITY OF MITCHELL COUNTY
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:
MEDICAL GROUP OF MITCHELL COUNTY
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:
1922211515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 CAIRO ROAD
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-227-5500
Provider Business Mailing Address Fax Number:
229-227-5505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 US HIGHWAY 19 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMILLA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31730-1410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-336-1949
Provider Business Practice Location Address Fax Number:
229-336-1436
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEMBREE
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VP/CFO
Authorized Official Telephone Number:
229-228-2853

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  101120 , 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: 11D1056726 . This is a "CLIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 841859123C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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