=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770865248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAULDING MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2011
-----------------------------------------------------
Last Update Date | 09/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W MEMORIAL DR WELLSTAR PAULDING HOSPITAL
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-443-4780
-----------------------------------------------------
Fax | 770-443-4782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WELLSTAR PAULDING HOSPITAL 600 W. MEMORIAL DRIVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-443-4780
-----------------------------------------------------
Fax | 770-443-4782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SITE ADMINISTRATOR
-----------------------------------------------------
Name | T. MARK HANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-445-4411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE009764
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------