Healthcare Provider Details

I. General information

NPI: 1285624452
Provider Name (Legal Business Name): HOSPITAL AUTHORITY OF RANDOLPH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MCDONALD AVE
CUTHBERT GA
39840-5829
US

IV. Provider business mailing address

361 RANDOLPH ST
CUTHBERT GA
39840-6127
US

V. Phone/Fax

Practice location:
  • Phone: 229-209-1322
  • Fax: 229-209-1324
Mailing address:
  • Phone: 229-732-2181
  • Fax: 229-209-1324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number048502
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier000320427D
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: STACEY L FLYNT
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 229-777-4514