Healthcare Provider Details

I. General information

NPI: 1366461857
Provider Name (Legal Business Name): EVANS MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 N DOWNING MUSGROVE HWY
GLENNVILLE GA
30427-2208
US

IV. Provider business mailing address

721 N DOWNING MUSGROVE HWY
GLENNVILLE GA
30427-2208
US

V. Phone/Fax

Practice location:
  • Phone: 912-654-2141
  • Fax:
Mailing address:
  • Phone: 912-654-2141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number11321521
License Number StateGA

VIII. Authorized Official

Name: MRS. MARTHA F TATUM
Title or Position: CEO
Credential:
Phone: 912-739-5105