Basic Information
| Provider Information | |||||||||
| NPI: | 1700851649 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRISP REGIONAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CRISP REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5007 | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310155007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292719686 | ||||||||
| FaxNumber: | 2292719689 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 7TH ST NORTH | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292719686 | ||||||||
| FaxNumber: | 2292719689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEARDEN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR REV INT | ||||||||
| AuthorizedOfficialTelephone: | 2292763146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | N | Hospitals | General Acute Care Hospital | Rural | 282NR1301X | 040495 | N | Hospitals | General Acute Care Hospital | Rural | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 282N00000X | 040495 | GA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000000514A | 05 | GA | MEDICAID |