Basic Information
| Provider Information | |||||||||
| NPI: | 1730433152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | UNIVERSITY HOSPITAL MCDUFFIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308246600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065951411 | ||||||||
| FaxNumber: | 7065975141 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308246600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065951411 | ||||||||
| FaxNumber: | 7065975139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2012 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | KEPSHIRE | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR / CNO | ||||||||
| AuthorizedOfficialTelephone: | 7065951411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS, MA, RN, CENP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.