Basic Information
Provider Information | |||||||||
NPI: | 1124192604 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TAYLOR REGIONAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAYLOR REGIONAL HOSPITAL EMS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1297 | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310367297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787830200 | ||||||||
FaxNumber: | 4788920518 | ||||||||
Practice Location | |||||||||
Address1: | 222 PERRY HWY | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310366748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787830200 | ||||||||
FaxNumber: | 4787832731 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 12/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNDON | ||||||||
AuthorizedOfficialFirstName: | SANDRA | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4787830200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 116-05 | GA | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 000001548C | 05 | GA |   | MEDICAID |