Basic Information
Provider Information | |||||||||
NPI: | 1487822912 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRISP REGIONAL HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 910 N 5TH ST | ||||||||
Address2: |   | ||||||||
City: | CORDELE | ||||||||
State: | GA | ||||||||
PostalCode: | 310153254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292719686 | ||||||||
FaxNumber: | 2292719689 | ||||||||
Practice Location | |||||||||
Address1: | 910 N 5TH ST | ||||||||
Address2: |   | ||||||||
City: | CORDELE | ||||||||
State: | GA | ||||||||
PostalCode: | 31015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292719686 | ||||||||
FaxNumber: | 2292719689 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2008 | ||||||||
LastUpdateDate: | 09/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEARDEN | ||||||||
AuthorizedOfficialFirstName: | LYNN | ||||||||
AuthorizedOfficialMiddleName: | RENEE | ||||||||
AuthorizedOfficialTitleorPosition: | DIR REV INT | ||||||||
AuthorizedOfficialTelephone: | 2292763146 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 040R0003 | GA | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 760967211A | 05 | GA |   | MEDICAID |