Provider Demographics
NPI:1295279495
Name:STATEWIDE HEALTH CARE INC
Entity type:Organization
Organization Name:STATEWIDE HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:J CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-231-8958
Mailing Address - Street 1:102 OGLETHORPE PROFESSIONAL CT
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3600
Mailing Address - Country:US
Mailing Address - Phone:912-231-8958
Mailing Address - Fax:912-234-7701
Practice Address - Street 1:102 OGLETHORPE PROFESSIONAL CT
Practice Address - Street 2:SUITE 4
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3600
Practice Address - Country:US
Practice Address - Phone:912-231-8958
Practice Address - Fax:912-234-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000621288AMedicaid
GA000510243CMedicaid
GA000510243DMedicaid
GA000510529BMedicaid
GA000510529AAMedicaid
GA000510243BMedicaid
GA000510529YMedicaid