Basic Information
| Provider Information | |||||||||
| NPI: | 1114134772 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRISP REGIONAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARABI HEALTHCARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 BEDGOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ARABI | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317123669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292730116 | ||||||||
| FaxNumber: | 2292734853 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 BEDGOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ARABI | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317123669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292730116 | ||||||||
| FaxNumber: | 2292734853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VESTAL | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2292763100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRISP REGIONAL HOSPITAL, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00000514G | 05 | GA | MEDICAID |