Provider Demographics
NPI:1619182102
Name:TATTNALL HEALTHCARE LLC.
Entity Type:Organization
Organization Name:TATTNALL HEALTHCARE LLC.
Other - Org Name:GLENVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-557-1000
Mailing Address - Street 1:121 N CASWELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-2017
Mailing Address - Country:US
Mailing Address - Phone:912-654-1080
Mailing Address - Fax:
Practice Address - Street 1:121 N CASWELL ST
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-2017
Practice Address - Country:US
Practice Address - Phone:912-654-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2213Medicare ID - Type UnspecifiedMEDICARE NUMBER