Provider Demographics
NPI:1912379082
Name:HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Other - Org Name:JEFF DAVIS FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-375-7781
Mailing Address - Street 1:9 HESTER ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6323
Mailing Address - Country:US
Mailing Address - Phone:912-375-0418
Mailing Address - Fax:912-375-5775
Practice Address - Street 1:9 HESTER ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6323
Practice Address - Country:US
Practice Address - Phone:912-375-0418
Practice Address - Fax:912-375-5775
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GERORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-28
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty