Provider Demographics
NPI:1295095925
Name:CRH PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:CRH PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-1900
Mailing Address - Street 1:1100 WARD STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-1902
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:
Practice Address - Street 1:804 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NICHOLLS
Practice Address - State:GA
Practice Address - Zip Code:31554
Practice Address - Country:US
Practice Address - Phone:912-384-4024
Practice Address - Fax:912-384-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7930Medicare PIN