Basic Information
| Provider Information | |||||||||
| NPI: | 1275036568 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAYLOR REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MIDDLE GA PEDIATRICS AT ROCHELLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1297 | ||||||||
| Address2: | |||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310367297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878302004 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 792 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310792018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293657514 | ||||||||
| FaxNumber: | 4787832299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2018 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JONATHON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4787830261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.