Basic Information
| Provider Information | |||||||||
| NPI: | 1982600540 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PIEDMONT MCDUFFIE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308246600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065975201 | ||||||||
| FaxNumber: | 7065975139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308246600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065975201 | ||||||||
| FaxNumber: | 7065975139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, GOVERNMENT REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000001185A | 05 | GA | MEDICAID | 000001185B | 05 | GA | MEDICAID |