1942348040 NPI number — CAMPBELLTON-GRACEVILLE HOSPITAL

Table of content: (NPI 1942348040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942348040 NPI number — CAMPBELLTON-GRACEVILLE HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMPBELLTON-GRACEVILLE 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:
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:
1942348040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5470 COLLEGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRACEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32440-1304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-263-2459
Provider Business Mailing Address Fax Number:
850-263-3312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5429 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRACEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32440-1857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-263-4431
Provider Business Practice Location Address Fax Number:
850-263-3312
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
DENA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
850-263-4431

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME90551 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060622701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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