Provider Demographics
NPI:1205867256
Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Other - Org Name:MITCHELL COUNTY DIALYSIS FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HEMBREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2880
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 1:251 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1410
Practice Address - Country:US
Practice Address - Phone:229-336-5874
Practice Address - Fax:229-336-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001132261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000407327AMedicaid
GA113502Medicare Oscar/Certification