Basic Information
| Provider Information | |||||||||
| NPI: | 1881758753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLQUITT REGIONAL PRIMARY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3037 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317763037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853320 | ||||||||
| FaxNumber: | 2298901282 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 HOSPITAL PARK | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853320 | ||||||||
| FaxNumber: | 2298901282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 07/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LODGE | ||||||||
| AuthorizedOfficialFirstName: | C. | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2299853320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 14029 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00002021D | 05 | GA | MEDICAID | 00002021E | 05 | GA | MEDICAID |