Basic Information
| Provider Information | |||||||||
| NPI: | 1053388256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITAL AUTHORITY OF THE CITY OF BAINBRIDGE AND DECATUR COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HOSPITAL AND MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292463500 | ||||||||
| FaxNumber: | 2292468142 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHOTWELL ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292463500 | ||||||||
| FaxNumber: | 2292468142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAIRCLOTH | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2292468211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 43-112 | GA | N | Hospitals | General Acute Care Hospital | 314000000X | 1-043-500 | GA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 00001262T | 05 | GA | MEDICAID | 00001262S | 05 | GA | MEDICAID | 00141919A | 05 | GA | MEDICAID | 00001262A | 05 | GA | MEDICAID | 000307 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |