Healthcare Provider Details

I. General information

NPI: 1154373744
Provider Name (Legal Business Name): CAMPBELLTON-GRACEVILLE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 COLLEGE DR STE B
GRACEVILLE FL
32440-1859
US

IV. Provider business mailing address

5429 COLLEGE DR
GRACEVILLE FL
32440-1857
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4172
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4172
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4172
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4172
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4172
License Number StateFL

VIII. Authorized Official

Name: MS. JUDY AUSTIN
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 850-263-4431