Provider Demographics
NPI:1376750976
Name:CRISP REGIONAL HOSPITAL, INC
Entity Type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC
Other - Org Name:CRISP REGIONAL CONVENIENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-271-4676
Mailing Address - Street 1:216 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3275
Mailing Address - Country:US
Mailing Address - Phone:229-276-2000
Mailing Address - Fax:229-276-2184
Practice Address - Street 1:216 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3275
Practice Address - Country:US
Practice Address - Phone:229-271-9330
Practice Address - Fax:229-271-9245
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:2013-03-11
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
GA11-8907OtherMCR CCN