Provider Demographics
NPI:1154485415
Name:CHILDRENS MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:GRANVILLE
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-528-4546
Mailing Address - Street 1:PO BOX 7627
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-7627
Mailing Address - Country:US
Mailing Address - Phone:229-396-5830
Mailing Address - Fax:229-391-3686
Practice Address - Street 1:5488 N ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:OMEGA
Practice Address - State:GA
Practice Address - Zip Code:31775-3054
Practice Address - Country:US
Practice Address - Phone:229-528-4546
Practice Address - Fax:229-528-4841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty