Provider Demographics
NPI:1629041421
Name:HOSPITAL AUTHORITY OF RANDOLPH COUNTY
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF RANDOLPH COUNTY
Other - Org Name:RANDOLPH MEDICAL ASSOCIATES SHELLMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-209-1242
Mailing Address - Street 1:206 WEST RAILROAD STREET
Mailing Address - Street 2:
Mailing Address - City:SHELLMAN
Mailing Address - State:GA
Mailing Address - Zip Code:39886-5003
Mailing Address - Country:US
Mailing Address - Phone:229-679-5579
Mailing Address - Fax:
Practice Address - Street 1:206 WEST RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:SHELLMAN
Practice Address - State:GA
Practice Address - Zip Code:39886-5003
Practice Address - Country:US
Practice Address - Phone:229-679-5579
Practice Address - Fax:229-679-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA614225598AMedicaid
GA614225598AMedicaid
HOSP3Medicare PIN