Basic Information
| Provider Information | |||||||||
| NPI: | 1790942381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TATTNALL HOSPITAL COMPANY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OPTIM MEDICAL CENTER - TATTNALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102764 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125571000 | ||||||||
| FaxNumber: | 9125571009 | ||||||||
| Practice Location | |||||||||
| Address1: | 247 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304534605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125571000 | ||||||||
| FaxNumber: | 9125571009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 07/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUENTHNER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY OF COMM. HOSP. HOLD. CO. | ||||||||
| AuthorizedOfficialTelephone: | 3126278427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TATTNALL HOSPITAL COMPANY LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 132601 | GA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 000001878A | 05 | GA | MEDICAID |