Provider Demographics
NPI:1912099094
Name:COLQUITT REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:COLQUITT REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-3420
Mailing Address - Street 1:3131 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6925
Mailing Address - Country:US
Mailing Address - Phone:229-985-3420
Mailing Address - Fax:
Practice Address - Street 1:3131 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035-296282N00000X
GA035-01341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000002021AMedicaid
GA000005695AMedicaid
GA000457OtherBLUE CROSS PROVIDER NUMBE
GA110105Medicare Oscar/Certification
GA000002021AMedicaid