Provider Demographics
NPI:1154373744
Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Entity type:Organization
Organization Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-263-4431
Mailing Address - Street 1:5429 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-1857
Mailing Address - Country:US
Mailing Address - Phone:850-263-4431
Mailing Address - Fax:850-263-3312
Practice Address - Street 1:5429 COLLEGE DR STE B
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1859
Practice Address - Country:US
Practice Address - Phone:850-263-4431
Practice Address - Fax:850-263-3312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAMPBELLTON-GRACEVILLE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4172207Q00000X, 207R00000X, 207RE0101X, 207RG0300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060622700Medicaid
FL060622700Medicaid