Provider Demographics
NPI:1073537114
Name:EAST GEORGIA REGIONAL MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:EAST GEORGIA REGIONAL MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-925-4565
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-871-5437
Mailing Address - Fax:
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 206
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-871-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA249619966AMedicaid