Provider Demographics
NPI:1356636534
Name:HOSPITAL AUTHORITY OF LIBERTY COUNTY
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF LIBERTY COUNTY
Other - Org Name:LIBERTY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-369-9427
Mailing Address - Street 1:455 S MAIN STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4354
Mailing Address - Country:US
Mailing Address - Phone:912-876-5644
Mailing Address - Fax:912-877-6341
Practice Address - Street 1:455 S.MAIN STREET STE 104
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-876-5644
Practice Address - Fax:912-408-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA065972OtherSTATE LICENSE