Provider Demographics
NPI:1952421067
Name:TAYLOR TELFAIR REGIONAL HOSP-PHYSICIAN OFFICE
Entity Type:Organization
Organization Name:TAYLOR TELFAIR REGIONAL HOSP-PHYSICIAN OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-868-4147
Mailing Address - Street 1:RT ONE, HWY 341S, SUITE A
Mailing Address - Street 2:
Mailing Address - City:MCRAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-0150
Mailing Address - Country:US
Mailing Address - Phone:229-868-4122
Mailing Address - Fax:229-868-4124
Practice Address - Street 1:RT ONE, HWY 341S, SUITE A
Practice Address - Street 2:
Practice Address - City:MCRAE
Practice Address - State:GA
Practice Address - Zip Code:31055-0150
Practice Address - Country:US
Practice Address - Phone:229-868-4122
Practice Address - Fax:229-868-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037111171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHOSP209Medicare ID - Type Unspecified