Basic Information
| Provider Information | |||||||||
| NPI: | 1396749149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITAL AUTHORITY OF RANDOLPH COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RANDOLPH MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 RANDOLPH ST | ||||||||
| Address2: | |||||||||
| City: | CUTHBERT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398406127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2297323721 | ||||||||
| FaxNumber: | 2297326528 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 MCDONALD AVE | ||||||||
| Address2: | |||||||||
| City: | CUTHBERT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398405829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2297323721 | ||||||||
| FaxNumber: | 2297326528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | GILMAN | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2297322181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00001427C | 05 | GA | MEDICAID |