1225364524 NPI number — EAST GEORGIA HEALTHCARE CENTER INC

Table of content: (NPI 1225364524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225364524 NPI number — EAST GEORGIA HEALTHCARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST GEORGIA HEALTHCARE CENTER 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:
Provider Other Organization Name Type Code:
6
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:
1225364524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 N COLEMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWAINSBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30401-3530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-237-6262
Provider Business Mailing Address Fax Number:
478-237-9138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 BRAMPTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-0855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-764-9196
Provider Business Practice Location Address Fax Number:
912-764-8401
Provider Enumeration Date:
10/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SORRELLS
Authorized Official First Name:
JILL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
478-237-6262

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003108558A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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