Basic Information
| Provider Information | |||||||||
| NPI: | 1659761955 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHENS COUNTY HOSPITAL PHYSICIAN GROUP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 163 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | TOCCOA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305776820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062824200 | ||||||||
| FaxNumber: | 7068868045 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | TOCCOA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305776820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062824200 | ||||||||
| FaxNumber: | 7068868045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2015 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HESTER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062824200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEPHENS COUNTY HOSPITAL AUTHORIT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.