Provider Demographics
NPI:1083915524
Name:SCREVEN COUNTY HOSPITAL LLC
Entity Type:Organization
Organization Name:SCREVEN COUNTY HOSPITAL LLC
Other - Org Name:OPTIM MEDICAL CENTER - SCREVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:KLEINPETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-644-5300
Mailing Address - Street 1:210 E DERENNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6736
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:215 MIMS RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-1994
Practice Address - Country:US
Practice Address - Phone:912-564-7426
Practice Address - Fax:912-564-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA124-164275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001647SMedicaid
GA11Z312Medicare Oscar/Certification