=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083711691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TY COBB HEALTHCARE SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2006
-----------------------------------------------------
Last Update Date | 05/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 FRANKLIN SPRINGS ST
-----------------------------------------------------
City | ROYSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30662-3934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-245-5071
-----------------------------------------------------
Fax | 706-245-1411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 FRANKLIN SPRINGS ST PO BOX 589
-----------------------------------------------------
City | ROYSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30662-3934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-245-5071
-----------------------------------------------------
Fax | 706-245-1411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MISS KIMBERLY A MASSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-245-1290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NR1301X
-----------------------------------------------------
Taxonomy Name | Rural Acute Care Hospital
-----------------------------------------------------
License Number | 059-521
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------