Basic Information
| Provider Information | |||||||||
| NPI: | 1124155965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLQUITT REGIONAL MEDICAL CENTER DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | LOWRY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2299853420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 035296 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 000408845A | 05 | GA | MEDICAID |