Provider Demographics
NPI:1356547145
Name:CRISP RGNL HOSP INC
Entity type:Organization
Organization Name:CRISP RGNL HOSP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-273-1481
Mailing Address - Street 1:PO BOX 1033
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7033
Mailing Address - Country:US
Mailing Address - Phone:478-783-4988
Mailing Address - Fax:800-342-7671
Practice Address - Street 1:440 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036
Practice Address - Country:US
Practice Address - Phone:478-783-4988
Practice Address - Fax:800-342-7671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISP REGIONAL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-27
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10401446332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1031640002Medicare NSC