Provider Demographics
NPI:1518440254
Name:PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Entity Type:Organization
Organization Name:PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Other - Org Name:SOUTHERN REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-259-4706
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-991-8160
Mailing Address - Fax:770-909-2595
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-991-8160
Practice Address - Fax:770-909-2595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-710273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000404AMedicaid