Healthcare Provider Details

I. General information

NPI: 1942348040
Provider Name (Legal Business Name): CAMPBELLTON-GRACEVILLE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 COLLEGE DR
GRACEVILLE FL
32440-1857
US

IV. Provider business mailing address

5470 COLLEGE DR
GRACEVILLE FL
32440-1304
US

V. Phone/Fax

Practice location:
  • Phone: 850-263-4431
  • Fax: 850-263-3312
Mailing address:
  • Phone: 850-263-2459
  • Fax: 850-263-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME90551
License Number StateFL

VIII. Authorized Official

Name: MS. DENA R COOPER
Title or Position: CONTROLLER
Credential:
Phone: 850-263-4431