Basic Information
| Provider Information | |||||||||
| NPI: | 1417938846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACON COUNTY GENERAL HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 378 | ||||||||
| Address2: | 204 MEDICAL DRIVE | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370839999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156662147 | ||||||||
| FaxNumber: | 6156667052 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370839999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156662147 | ||||||||
| FaxNumber: | 6156667052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | KIDD | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6156662147 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 0000000080 | TN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 1000176 | 01 | TN | BLUE CROSS | OTHER | 0441305 | 05 | TN | MEDICAID |