Basic Information
| Provider Information | |||||||||
| NPI: | 1285688234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW PARK, LIMITED PARTNERSHIP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAIRVIEW PARK HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782752000 | ||||||||
| FaxNumber: | 4782720211 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782752000 | ||||||||
| FaxNumber: | 4782720211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOBLES | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4782743103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 02713293 | 05 | NY | MEDICAID | 0413831 | 05 | MT | MEDICAID | 2478439 | 05 | OH | MEDICAID | 912418700 | 05 | FL | MEDICAID | 11084A | 05 | SC | MEDICAID | 000001141A | 05 | GA | MEDICAID | 003123479 | 05 | CT | MEDICAID | 158180105 | 05 | AR | MEDICAID | 200332480A | 05 | KS | MEDICAID | 304845784 | 05 | MI | MEDICAID | 153 | 01 | GA | BLUE CROSS | OTHER | 1702820 | 05 | LA | MEDICAID | 4022419 | 01 | TN | BLUECARE | OTHER | 807291800 | 05 | ID | MEDICAID | 166597300 | 01 | DEPT OF LABOR | OTHER | 4101901 | 05 | NJ | MEDICAID |