Provider Demographics
NPI:1659416725
Name:SOUTHERN REGIONAL MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:SOUTHERN REGIONAL MEDICAL CENTER, INC
Other - Org Name:INPATIENT REHAB UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-991-8165
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:INPATIENT REHAB
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-991-8000
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:INPATIENT REHAB
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-991-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11T165Medicare ID - Type UnspecifiedPROVIDER NUMBER