=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154794857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRH PHYSICIAN PRACTICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2015
-----------------------------------------------------
Last Update Date | 11/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 ALICE ST
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-384-5832
-----------------------------------------------------
Fax | 912-383-8279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14804
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-384-5832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT DIRECTOR
-----------------------------------------------------
Name | NICOLE BURNAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-260-5379
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------