Healthcare Provider Details

I. General information

NPI: 1629101779
Provider Name (Legal Business Name): HOSPITAL AUTHORITY OF VALDOSTA & LOWNDES COUNTY, GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N PATTERSON ST
VALDOSTA GA
31602-1735
US

IV. Provider business mailing address

2209 PINEVIEW DR
VALDOSTA GA
31602-7316
US

V. Phone/Fax

Practice location:
  • Phone: 229-259-4938
  • Fax: 229-259-4925
Mailing address:
  • Phone: 229-671-6675
  • Fax: 229-245-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberPHH006327
License Number StateGA

VIII. Authorized Official

Name: MR. MICHAEL LANE
Title or Position: ADMINISTRATOR
Credential:
Phone: 229-671-6601