Provider Demographics
NPI:1760548002
Name:CHARLTON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CHARLTON MEMORIAL HOSPITAL
Other - Org Name:FAMILY PRACTICE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCASLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-496-2697
Mailing Address - Street 1:2383 THIRD ST
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-8917
Mailing Address - Country:US
Mailing Address - Phone:912-496-2697
Mailing Address - Fax:912-496-1139
Practice Address - Street 1:2383 THIRD ST
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-8917
Practice Address - Country:US
Practice Address - Phone:912-496-2697
Practice Address - Fax:912-496-1139
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLTON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA814096430AMedicaid
GAHOSP45OtherMEDICARE PART B PTAN
GA164482236AMedicaid
GAHOSP45OtherMEDICARE PART B PTAN