Basic Information
| Provider Information | |||||||||
| NPI: | 1255680062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAYLOR REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TAYLOR PHYSICIANS PRACTICE # 12 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1297 | ||||||||
| Address2: | |||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310367297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787830200 | ||||||||
| FaxNumber: | 4787832731 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 E PEACOCK ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | COCHRAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310147846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789340776 | ||||||||
| FaxNumber: | 4789340779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | PAULK | ||||||||
| AuthorizedOfficialFirstName: | NIKKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4787830200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.