Healthcare Provider Details

I. General information

NPI: 1063856243
Provider Name (Legal Business Name): ARCHBOLD PHYSICAL MEDICINE AND REHAB OF SOUTH GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 SMITH AVE
THOMASVILLE GA
31792-5533
US

IV. Provider business mailing address

900 CAIRO RD
THOMASVILLE GA
31792-4255
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-9412
  • Fax: 229-226-4492
Mailing address:
  • Phone: 229-227-5158
  • Fax: 229-227-5187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number041159
License Number StateGA

VIII. Authorized Official

Name: MR. CHARLES HIGHTOWER
Title or Position: CFO
Credential:
Phone: 229-228-2853