Basic Information
| Provider Information | |||||||||
| NPI: | 1306869003 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLYNN-BRUNSWICK MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHEAST GEORGIA HEALTH SYSTEM - TRANSITIONAL CARE UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667000 | ||||||||
| FaxNumber: | 9124667026 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667000 | ||||||||
| FaxNumber: | 9124667026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHERNECK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9124667049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-121-1535 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00830827A | 05 | GA | MEDICAID | 51000165 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |