Provider Demographics
NPI:1760402424
Name:ADVENTIST HEALTH SYSTEM GEORGIA, INC.
Entity Type:Organization
Organization Name:ADVENTIST HEALTH SYSTEM GEORGIA, INC.
Other - Org Name:GORDON HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-879-4710
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:706-879-4710
Mailing Address - Fax:706-629-4842
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2082
Practice Address - Country:US
Practice Address - Phone:706-879-4710
Practice Address - Fax:706-629-4842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064-0334282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000833AMedicaid
GA000000833AMedicaid
GA100021OtherSTATE MERIT PROGRAM
GA100021OtherSTATE HEALTH BENEFIT PLAN
GA307010000OtherCHAMPUS TRICARE
GA000000833AMedicaid
GA=========OtherMOHAWK CARPET
GA=========OtherSHAW MEDICAL CLAIMS CENTE
GA000000833AMedicaid