1497992457 NPI number — SOUTHWESTERN STATE HOSPITAL

Table of content: (NPI 1497992457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497992457 NPI number — SOUTHWESTERN STATE HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWESTERN STATE HOSPITAL
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:
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:
1497992457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1378
Provider Second Line Business Mailing Address:
PATIENT BILLING DEPT
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31799-1378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-227-2977
Provider Business Mailing Address Fax Number:
229-227-2955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309A SHORELINE DR
Provider Second Line Business Practice Location Address:
COMMUNITY MEDICAID COMP WAIVER HOME
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31757-2577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-227-2977
Provider Business Practice Location Address Fax Number:
229-227-2955
Provider Enumeration Date:
01/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HOO-YOU
Authorized Official First Name:
HILARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official Telephone Number:
229-227-3020

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  320900000X , 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: 304774584I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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