Provider Demographics
NPI:1386675817
Name:EARLY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:EARLY MEMORIAL HOSPITAL
Other - Org Name:BLAKELY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
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:229-227-5500
Mailing Address - Fax:229-227-5505
Practice Address - Street 1:11168 COLUMBIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-3474
Practice Address - Country:US
Practice Address - Phone:229-723-4313
Practice Address - Fax:229-723-3734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4945261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
11D0265994OtherCLIA
GA000000635IMedicaid
GA118509Medicare Oscar/Certification