Provider Demographics
NPI:1114134772
Name:CRISP REGIONAL HOSPITAL, INC
Entity Type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC
Other - Org Name:ARABI HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VESTAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-276-3100
Mailing Address - Street 1:4110 BEDGOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ARABI
Mailing Address - State:GA
Mailing Address - Zip Code:31712-3669
Mailing Address - Country:US
Mailing Address - Phone:229-273-0116
Mailing Address - Fax:229-273-4853
Practice Address - Street 1:4110 BEDGOOD AVE
Practice Address - Street 2:
Practice Address - City:ARABI
Practice Address - State:GA
Practice Address - Zip Code:31712-3669
Practice Address - Country:US
Practice Address - Phone:229-273-0116
Practice Address - Fax:229-273-4853
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISP REGIONAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000514GMedicaid
GA113400Medicare Oscar/Certification
GA113400Medicare PIN