Basic Information
Provider Information | |||||||||
NPI: | 1720339336 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TAYLOR REGIONAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDDLE GA PEDIATRICS AT HAWKINSVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1297 | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310367297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787830200 | ||||||||
FaxNumber: | 4787832731 | ||||||||
Practice Location | |||||||||
Address1: | 222 PERRY HWY | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310366748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787834080 | ||||||||
FaxNumber: | 4787832299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2012 | ||||||||
LastUpdateDate: | 04/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAULK | ||||||||
AuthorizedOfficialFirstName: | NIKKI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 4787830200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.