Basic Information
Provider Information | |||||||||
NPI: | 1386819803 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTMAN MEDICAL SERVICES,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTMAN MEDICAL SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1085 PLAZA AVE | ||||||||
Address2: |   | ||||||||
City: | EASTMAN | ||||||||
State: | GA | ||||||||
PostalCode: | 310239102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783747762 | ||||||||
FaxNumber: | 4783741177 | ||||||||
Practice Location | |||||||||
Address1: | 1085 PLAZA AVE | ||||||||
Address2: |   | ||||||||
City: | EASTMAN | ||||||||
State: | GA | ||||||||
PostalCode: | 310239102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783747762 | ||||||||
FaxNumber: | 4783741177 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2008 | ||||||||
LastUpdateDate: | 04/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HESTER | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO (DODGE COUNTY HOSPITAL) | ||||||||
AuthorizedOfficialTelephone: | 4784484050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.