Basic Information
| Provider Information | |||||||||
| NPI: | 1013933944 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURKE COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BURKE MEDICAL CENTER HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 S LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308309686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064372655 | ||||||||
| FaxNumber: | 7065444854 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065542176 | ||||||||
| FaxNumber: | 7065546407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | STEINER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7065544435 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7856 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | 7856 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00665959A | 05 | GA | MEDICAID |