Basic Information
| Provider Information | |||||||||
| NPI: | 1780638833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARTERSVILLE MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARTERSVILLE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 JOE FRANK HARRIS PKWY SE | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703821530 | ||||||||
| FaxNumber: | 7706062127 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOE FRANK HARRIS PKWY SE | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703821530 | ||||||||
| FaxNumber: | 7706062127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP GOVERNMENT REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 158337300 | 01 | DEPT OF LABOR | OTHER | 269740 | 05 | OR | MEDICAID | 82554300 | 05 | WI | MEDICAID | 29686521 | 05 | CO | MEDICAID | 04935056 | 05 | MS | MEDICAID | 11066A | 05 | SC | MEDICAID | 1131399 | 05 | KY | MEDICAID | 01698 | 05 | ND | MEDICAID | 3075476 | 01 | TN | BLUECARE | OTHER | 3570 | 01 | GA | BLUE CROSS | OTHER | 911642700 | 05 | FL | MEDICAID | 000001625A | 05 | GA | MEDICAID | 01300318 | 05 | KY | MEDICAID | 100504458 | 05 | NV | MEDICAID | 1704857 | 05 | LA | MEDICAID | 089328 | 05 | AZ | MEDICAID | 146981901 | 05 | TX | MEDICAID | 60022246 | 05 | NJ | MEDICAID | EMO0030N | 05 | AL | MEDICAID | 0018091580003 | 05 | PA | MEDICAID | 0110030 | 05 | TN | MEDICAID | 1012487 | 05 | MI | MEDICAID | 2339222 | 05 | OH | MEDICAID |