Basic Information
Provider Information | |||||||||
NPI: | 1265597835 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGIONAL FIRSTCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 OGLETHORPE AVE | ||||||||
Address2: | STE 600A | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306062179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7064754920 | ||||||||
FaxNumber: | 7062088259 | ||||||||
Practice Location | |||||||||
Address1: | 1010 VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | WATKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 306776004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067690000 | ||||||||
FaxNumber: | 7067690320 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 12/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RANSFORD-DES JARDINES | ||||||||
AuthorizedOfficialFirstName: | SHELLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7064754921 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 027103 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GRP3190 | 01 | GA | MEDICARE GROUP NUMBER | OTHER |