Basic Information
| Provider Information | |||||||||
| NPI: | 1386995694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAYLOR REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TAYLOR PHYSICIANS PRACTICE # 4 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1297 | ||||||||
| Address2: | |||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310367297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787830200 | ||||||||
| FaxNumber: | 4787832731 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PERRY HWY | ||||||||
| Address2: | BLDG A, STE 105 | ||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310366748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787834307 | ||||||||
| FaxNumber: | 4787834309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | PAULK | ||||||||
| AuthorizedOfficialFirstName: | NIKKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4787830200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.