Provider Demographics
NPI:1417076266
Name:TAYLOR TELFAIR REGIONAL HOSP-PHYSICIAN OFFICE
Entity Type:Organization
Organization Name:TAYLOR TELFAIR REGIONAL HOSP-PHYSICIAN OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-868-4147
Mailing Address - Street 1:903 WILLOW CREEK LANE
Mailing Address - Street 2:PHYSICIANS OFFICE
Mailing Address - City:MCRAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-0150
Mailing Address - Country:US
Mailing Address - Phone:229-868-5271
Mailing Address - Fax:229-868-2574
Practice Address - Street 1:903 WILLOW CREEK LANE
Practice Address - Street 2:PHYSICIANS OFFICE
Practice Address - City:MCRAE
Practice Address - State:GA
Practice Address - Zip Code:31055-0150
Practice Address - Country:US
Practice Address - Phone:229-868-5271
Practice Address - Fax:229-868-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050874174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDWPWMedicare ID - Type Unspecified
GA08CBCBWMedicare ID - Type Unspecified
GA11SCFVKMedicare ID - Type Unspecified