Provider Demographics
NPI:1912902263
Name:HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Entity Type:Organization
Organization Name:HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Other - Org Name:JEFF DAVIS HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-375-7781
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-1690
Mailing Address - Country:US
Mailing Address - Phone:912-375-7781
Mailing Address - Fax:912-375-4055
Practice Address - Street 1:163 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-1690
Practice Address - Country:US
Practice Address - Phone:912-375-7781
Practice Address - Fax:912-375-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001009AMedicaid
GA000001009AMedicaid