=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467091389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEADOWS REGIONAL MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2019
-----------------------------------------------------
Last Update Date | 12/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1707 MEADOWS LN STE B
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30474-7201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-535-7100
-----------------------------------------------------
Fax | 912-535-7120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 407
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30475-0407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-535-5581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TONY M O'STEEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-535-8691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------