Provider Demographics
NPI:1114014669
Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Other - Org Name:COOLIDGE PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
Mailing Address - Street 1:920 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:229-228-8800
Mailing Address - Fax:229-228-8892
Practice Address - Street 1:1034 SOUTH PINE STREET
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:GA
Practice Address - Zip Code:31738
Practice Address - Country:US
Practice Address - Phone:229-346-3511
Practice Address - Fax:229-346-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA136-91261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000063FMedicaid
GA000000063FMedicaid