Basic Information
| Provider Information | |||||||||
| NPI: | 1891925608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EFFINGHAM HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | EFFINGHAM FAMILY MEDICINE AT PORT WENTWORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 459 HIGHWAY 119 SOUTH | ||||||||
| Address2: | ATTN.: ALIA ALLEN/MEDICAL STAFF OFFICE | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127540175 | ||||||||
| FaxNumber: | 9127546395 | ||||||||
| Practice Location | |||||||||
| Address1: | 7306 GA HIGHWAY 21 | ||||||||
| Address2: | STE 105 | ||||||||
| City: | PORT WENTWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314079275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129662575 | ||||||||
| FaxNumber: | 9129660906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | BAKER-WITT | ||||||||
| AuthorizedOfficialFirstName: | FRANCINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 9127540142 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN, MBA, CNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | HOSP150 | 01 | GA | MEDICARE | OTHER |