=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629041421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOSPITAL AUTHORITY OF RANDOLPH COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 02/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 WEST RAILROAD STREET
-----------------------------------------------------
City | SHELLMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 39886-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-679-5579
-----------------------------------------------------
Fax | 229-679-5584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 WEST RAILROAD STREET
-----------------------------------------------------
City | SHELLMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 39886-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-679-5579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KIM GILMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-209-1242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------