Provider Demographics
NPI:1932296811
Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC.
Other - Org Name:PAVO PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
Mailing Address - Street 1:920 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4255
Mailing Address - Country:US
Mailing Address - Phone:229-228-8800
Mailing Address - Fax:229-228-8892
Practice Address - Street 1:1103 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PAVO
Practice Address - State:GA
Practice Address - Zip Code:31778
Practice Address - Country:US
Practice Address - Phone:229-859-2622
Practice Address - Fax:229-859-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA136-91261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000063HMedicaid
GA000000063HMedicaid