Provider Demographics
NPI:1508910241
Name:RURAL HEALTH CENTER OF SOUTHEAST GA.,INC.
Entity Type:Organization
Organization Name:RURAL HEALTH CENTER OF SOUTHEAST GA.,INC.
Other - Org Name:FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-538-0830
Mailing Address - Street 1:300 ARLINGTON DR.
Mailing Address - Street 2:PO BOX 645
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0645
Mailing Address - Country:US
Mailing Address - Phone:912-538-0830
Mailing Address - Fax:912-538-1333
Practice Address - Street 1:300 ARLINGTON DR.
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-538-0830
Practice Address - Fax:912-538-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00741243AMedicaid
GA00741243AMedicaid