Provider Demographics
NPI:1285624452
Name:HOSPITAL AUTHORITY OF RANDOLPH COUNTY
Entity type:Organization
Organization Name:HOSPITAL AUTHORITY OF RANDOLPH COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLYNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-777-4514
Mailing Address - Street 1:361 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840-6127
Mailing Address - Country:US
Mailing Address - Phone:229-732-2181
Mailing Address - Fax:229-209-1324
Practice Address - Street 1:125 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-5829
Practice Address - Country:US
Practice Address - Phone:229-209-1322
Practice Address - Fax:229-209-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048502261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000320427DMedicaid
GA000320427DMedicaid
GAHOSP3Medicare PIN