Provider Demographics
NPI:1720444789
Name:GENEVAL COUNTY HEALTH CARE AUTHORITY, INC.
Entity Type:Organization
Organization Name:GENEVAL COUNTY HEALTH CARE AUTHORITY, INC.
Other - Org Name:WIREGRASS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-684-3655
Mailing Address - Street 1:24245 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORALA
Mailing Address - State:AL
Mailing Address - Zip Code:36442-3523
Mailing Address - Country:US
Mailing Address - Phone:334-684-3655
Mailing Address - Fax:
Practice Address - Street 1:24245 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLORALA
Practice Address - State:AL
Practice Address - Zip Code:36442-3523
Practice Address - Country:US
Practice Address - Phone:334-684-3655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-0062Medicare UPIN