Provider Demographics
NPI:1942348040
Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Entity Type:Organization
Organization Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Other - Org Name:GRACEVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-263-4431
Mailing Address - Street 1:5470 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-1304
Mailing Address - Country:US
Mailing Address - Phone:850-263-2459
Mailing Address - Fax:850-263-3312
Practice Address - Street 1:5429 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1857
Practice Address - Country:US
Practice Address - Phone:850-263-4431
Practice Address - Fax:850-263-3312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAMPBELLTON-GRACEVILLE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90551207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060622701Medicaid