Healthcare Provider Details

I. General information

NPI: 1760717433
Provider Name (Legal Business Name): EVANS MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 A E. LONG ST.
CLAXTON GA
30417
US

IV. Provider business mailing address

200 N RIVER ST
CLAXTON GA
30417-1659
US

V. Phone/Fax

Practice location:
  • Phone: 912-739-5932
  • Fax: 912-739-5933
Mailing address:
  • Phone: 912-739-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN WIGGINS
Title or Position: CEO
Credential:
Phone: 912-739-5000