=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366461857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVANS MEMORIAL HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 N DOWNING MUSGROVE HWY
-----------------------------------------------------
City | GLENNVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30427-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-654-2141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 N DOWNING MUSGROVE HWY
-----------------------------------------------------
City | GLENNVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30427-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-654-2141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. MARTHA F TATUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-739-5105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 11321521
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------