Provider Demographics
NPI:1578637526
Name:BLECKLEY COUNTY HOSPITAL
Entity Type:Organization
Organization Name:BLECKLEY COUNTY HOSPITAL
Other - Org Name:BLECKLEY MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:NOBLES
Authorized Official - Last Name:PAULK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:478-934-6211
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:145 EAST PEACOCK STREET
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-0536
Mailing Address - Country:US
Mailing Address - Phone:478-934-6211
Mailing Address - Fax:
Practice Address - Street 1:145 E PEACOCK ST
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-7846
Practice Address - Country:US
Practice Address - Phone:478-934-6211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012-233282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA271242OtherWELLCARE
GA00000195AMedicaid
GA115917OtherPEACHSTATE
GA00000195AMedicaid
GA=========OtherBLUE CROSS
GA111302Medicare ID - Type UnspecifiedMEDICARE