Healthcare Provider Details

I. General information

NPI: 1144298548
Provider Name (Legal Business Name): FANNIN REGIONAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

772 MADDOX DR STE 126
EAST ELLIJAY GA
30540-8194
US

IV. Provider business mailing address

PO BOX 198161
ATLANTA GA
30384-8161
US

V. Phone/Fax

Practice location:
  • Phone: 706-273-2105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number055-452
License Number StateGA

VIII. Authorized Official

Name: LAURIE HOLTSFORD
Title or Position: SENIOR VP, GROUP OPERATIONS
Credential:
Phone: 615-465-7466