Provider Demographics
NPI:1790942381
Name:TATTNALL HOSPITAL COMPANY, LLC
Entity Type:Organization
Organization Name:TATTNALL HOSPITAL COMPANY, LLC
Other - Org Name:OPTIM MEDICAL CENTER - TATTNALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY OF COMM. HOSP. HOLD. CO.
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUENTHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-627-8427
Mailing Address - Street 1:PO BOX 102764
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2764
Mailing Address - Country:US
Mailing Address - Phone:912-557-1000
Mailing Address - Fax:912-557-1009
Practice Address - Street 1:247 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4605
Practice Address - Country:US
Practice Address - Phone:912-557-1000
Practice Address - Fax:912-557-1009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TATTNALL HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-21
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA132601282NC0060X
282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001878AMedicaid
GA000001878AMedicaid