Provider Demographics
NPI:1063856243
Name:ARCHBOLD PHYSICAL MEDICINE AND REHAB OF SOUTH GEORGIA
Entity Type:Organization
Organization Name:ARCHBOLD PHYSICAL MEDICINE AND REHAB OF SOUTH GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
Mailing Address - Street 1:900 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4255
Mailing Address - Country:US
Mailing Address - Phone:229-227-5158
Mailing Address - Fax:229-227-5187
Practice Address - Street 1:334 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5533
Practice Address - Country:US
Practice Address - Phone:229-226-9412
Practice Address - Fax:229-226-4492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARCHBOLD MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-18
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041159208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty