Provider Demographics
NPI:1578746608
Name:MEDTRUST, INC
Entity Type:Organization
Organization Name:MEDTRUST, INC
Other - Org Name:WESTSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-868-5650
Mailing Address - Street 1:3940 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5247
Mailing Address - Country:US
Mailing Address - Phone:706-868-5650
Mailing Address - Fax:706-868-0675
Practice Address - Street 1:3940 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5247
Practice Address - Country:US
Practice Address - Phone:706-868-5650
Practice Address - Fax:706-868-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2241Medicare PIN