Basic Information
| Provider Information | |||||||||
| NPI: | 1265579072 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TATTNALL HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TATTNALL COMMUNITY HOSPITAL-SWING BED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 247 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304534605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125571000 | ||||||||
| FaxNumber: | 9125571009 | ||||||||
| Practice Location | |||||||||
| Address1: | 247 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304534605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125571000 | ||||||||
| FaxNumber: | 9125571009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O | ||||||||
| AuthorizedOfficialTelephone: | 9125571000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HEALTHCARE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 132-601 | GA | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.