Healthcare Provider Details

I. General information

NPI: 1174555734
Provider Name (Legal Business Name): EARLY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 COLUMBIA ST
BLAKELY GA
39823-2574
US

IV. Provider business mailing address

920 CAIRO RD
THOMASVILLE GA
31792-4255
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-3794
  • Fax: 229-723-8024
Mailing address:
  • Phone: 229-228-8800
  • Fax: 229-228-8892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-049-409
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000140874A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. CHARLES D. HIGHTOWER JR.
Title or Position: CFO
Credential:
Phone: 229-228-2853