Provider Demographics
NPI:1093737041
Name:PROVIDENT HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:PROVIDENT HEALTH SERVICES, INC.
Other - Org Name:MEMORIAL HEALTH HOSPITALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:MEMORIAL HEALTH HOSPITALISTS
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2155
Mailing Address - Fax:912-350-2156
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:MEMORIAL HEALTH HOSPITALISTS
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-2155
Practice Address - Fax:912-350-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA609293670AMedicaid
SCGPA896Medicaid
GA609293670AMedicaid
GADA3772Medicare PIN
SCDF7661Medicare PIN
SCGPA896Medicaid