Provider Demographics
NPI:1902013048
Name:CRISP REGIONAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:CRISP REGIONAL HOSPITAL, INC.
Other - Org Name:ROCHELLE HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-271-4676
Mailing Address - Street 1:636 SECOND AVENUE, SW
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:GA
Mailing Address - Zip Code:31079
Mailing Address - Country:US
Mailing Address - Phone:229-365-2570
Mailing Address - Fax:229-365-2571
Practice Address - Street 1:636 SECOND AVENUE, SW
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:GA
Practice Address - Zip Code:31079
Practice Address - Country:US
Practice Address - Phone:229-365-2570
Practice Address - Fax:229-365-2571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISP REGIONAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-17
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000514HMedicaid
GA113485Medicare ID - Type Unspecified