Basic Information
| Provider Information | |||||||||
| NPI: | 1699740498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRISP REGIONAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRISP REGIONAL HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 310153254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292763100 | ||||||||
| FaxNumber: | 2292763297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | AUDITOR | ||||||||
| AuthorizedOfficialTelephone: | 2292763100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 040063H | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 000784198A | 05 | GA | MEDICAID |