Basic Information
Provider Information | |||||||||
NPI: | 1881798965 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 WATERS AVE | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314046220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123503719 | ||||||||
FaxNumber: | 9123503948 | ||||||||
Practice Location | |||||||||
Address1: | 4700 WATERS AVE | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314046220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123507109 | ||||||||
FaxNumber: | 9123503058 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2006 | ||||||||
LastUpdateDate: | 05/15/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOW | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9123508613 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 025-377 | GA | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 001217 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 091693500 | 05 | FL |   | MEDICAID | 117736 | 05 | SC |   | MEDICAID | FACILITY # 1405 | 01 |   | NATIONALLY ASSIGNED | OTHER | 456640 | 05 | SC |   | MEDICAID | 486 | 01 | GA | MEDICAID CMO | OTHER | 00001273A | 05 | GA |   | MEDICAID | 10006521 | 01 | GA | MEDICAID CMO | OTHER |