Basic Information
| Provider Information | |||||||||
| NPI: | 1356344915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHATTAHOOCHEE VALLEY HOSPITAL SOCIETY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LANIER HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 48TH ST | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368543666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347569180 | ||||||||
| FaxNumber: | 3347566678 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 48TH ST | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368543666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347569180 | ||||||||
| FaxNumber: | 3347565874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEROY | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CIO | ||||||||
| AuthorizedOfficialTelephone: | 3347569180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 10478 | AL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00061773A | 05 | GA | MEDICAID | 1912929068 | 01 | AL | FAGAN NPI | OTHER | HOS0025H | 05 | AL | MEDICAID | PEC0025H | 05 | AL | MEDICAID | 529929850 | 05 | AL | MEDICAID | 010076 | 01 | AL | BCBS HOSP PROVIDER # | OTHER |