Basic Information
Provider Information | |||||||||
NPI: | 1063753689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOSPITAL AUTHORITY OF VALDOSTA AND LOWNDES COUNTY, GEORGIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SGMC BERRIEN CAMPUS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | VALDOSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 316030009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2295437100 | ||||||||
FaxNumber: | 2292456232 | ||||||||
Practice Location | |||||||||
Address1: | 1221 E MCPHERSON AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 316392326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2295437100 | ||||||||
FaxNumber: | 2295431724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2013 | ||||||||
LastUpdateDate: | 08/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HODGES | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2292594140 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOSPITAL AUTHORITY OF VALDOSTA AND LOWNDES COUNTY, GEORGIA | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 010691 | GA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 000000173A | 05 | GA |   | MEDICAID |