Provider Demographics
NPI:1710901178
Name:FORT PAYNE HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:FORT PAYNE HOSPITAL CORPORATION
Other - Org Name:DEKALB REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE OPERATIONS/AO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3840
Mailing Address - Street 1:PO BOX 277507
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL CENTER DR SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3458
Practice Address - Country:US
Practice Address - Phone:256-845-3150
Practice Address - Fax:256-997-2512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL012866282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
010-109OtherBCBS
ALHOS0012HMedicaid
=========OtherTRICARE
010-109OtherBCBS