Basic Information
| Provider Information | |||||||||
| NPI: | 1912099094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 SOUTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3131 SOUTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | MATNEY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 2299853420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 035-01 | GA | N | Transportation Services | Ambulance | 282N00000X | 035-296 | GA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000002021A | 05 | GA | MEDICAID | 000005695A | 05 | GA | MEDICAID | 000457 | 01 | GA | BLUE CROSS PROVIDER NUMBE | OTHER |