Basic Information
Provider Information | |||||||||
NPI: | 1295883445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHCARE OF BERRIEN COUNTY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BERRIEN COUNTY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1221 E MCPHERSON AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 316392326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2295437318 | ||||||||
FaxNumber: | 2295431724 | ||||||||
Practice Location | |||||||||
Address1: | 1221 E MCPHERSON AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 316392326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2295437318 | ||||||||
FaxNumber: | 2295431724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2007 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLETCHER | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2295437314 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 010-390 | GA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | N191557 | 01 | GA | WELLCARE CMO | OTHER | 00000173A | 05 | GA |   | MEDICAID | 115916 | 01 | GA | PEACHCARE CMO | OTHER | 52 | 01 | GA | BLUE CROSS BLUE SHIE | OTHER |