Healthcare Provider Details

I. General information

NPI: 1154795581
Provider Name (Legal Business Name): PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

IV. Provider business mailing address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8000
  • Fax:
Mailing address:
  • Phone: 770-991-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number031-442
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER DOAN
Title or Position: MANAGING ASSOCIATE GENERAL COUNSEL
Credential:
Phone: 310-259-4706