Basic Information
| Provider Information | |||||||||
| NPI: | 1437536372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY HOSPITAL MCDUFFIE--SWINGBED UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 WASHINGTON ROAD NE | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308242199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065951411 | ||||||||
| FaxNumber: | 7065975139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 WASHINGTON ROAD NE | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308242199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065951411 | ||||||||
| FaxNumber: | 7065975139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP GOVERNMENT REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 00001185 | 05 | GA | MEDICAID | 11-0111 | 01 | PARENT MEDICARE CCN | OTHER |