Provider Demographics
NPI:1457329377
Name:CRISP REGIONAL HOSPITAL, INC
Entity Type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC
Other - Org Name:CRISP REGIONAL DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERNAL AUDITOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-276-3100
Mailing Address - Street 1:902 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3234
Mailing Address - Country:US
Mailing Address - Phone:229-271-9686
Mailing Address - Fax:229-271-9689
Practice Address - Street 1:902 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-3100
Practice Address - Fax:229-276-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001001261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000431351AMedicaid
GA000431351AMedicaid