Basic Information
Provider Information | |||||||||
NPI: | 1194744326 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST GEORGIA HEALTH SYSTEM, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHEAST GEORGIA HEALTH SYSTEM - CAMDEN CAMPUS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 DAN PROCTOR DR | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | GA | ||||||||
PostalCode: | 315583810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9125766200 | ||||||||
FaxNumber: | 9125766404 | ||||||||
Practice Location | |||||||||
Address1: | 2000 DAN PROCTOR DR | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | GA | ||||||||
PostalCode: | 315583810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9125766200 | ||||||||
FaxNumber: | 9125766404 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAYNES | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 9124667049 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA, MA | ||||||||
NPICertificationDate: | 02/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 020-472 | GA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 00000811A | 05 | GA |   | MEDICAID | 51000164 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |