Provider Demographics
NPI:1366461857
Name:EVANS MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:EVANS MEMORIAL HOSPITAL, INC.
Other - Org Name:GLENVUE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:F
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-739-5105
Mailing Address - Street 1:721 N DOWNING MUSGROVE HWY
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-2208
Mailing Address - Country:US
Mailing Address - Phone:912-654-2141
Mailing Address - Fax:
Practice Address - Street 1:721 N DOWNING MUSGROVE HWY
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-2208
Practice Address - Country:US
Practice Address - Phone:912-654-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11321521313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00141171AMedicaid
GA00141171AMedicaid