Basic Information
| Provider Information | |||||||||
| NPI: | 1902013048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRISP REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ROCHELLE HEALTHCARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 636 SECOND AVENUE, SW | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293652570 | ||||||||
| FaxNumber: | 2293652571 | ||||||||
| Practice Location | |||||||||
| Address1: | 636 SECOND AVENUE, SW | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293652570 | ||||||||
| FaxNumber: | 2293652571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2292714676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRISP REGIONAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00000514H | 05 | GA | MEDICAID |