Basic Information
| Provider Information | |||||||||
| NPI: | 1417932583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSPAN LLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BURKE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 S LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308309686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065544435 | ||||||||
| FaxNumber: | 7065544435 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 S LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308309686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065544435 | ||||||||
| FaxNumber: | 7065544435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROYAL | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7065544435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 017563 | GA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00000283A | 05 | GA | MEDICAID |