Provider Demographics
NPI:1306143839
Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Entity type:Organization
Organization Name:CAMPBELLTON-GRACEVILLE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-263-4431
Mailing Address - Street 1:5429 COLLEGE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-1858
Mailing Address - Country:US
Mailing Address - Phone:850-263-0639
Mailing Address - Fax:850-263-9726
Practice Address - Street 1:5429 COLLEGE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1858
Practice Address - Country:US
Practice Address - Phone:850-263-0639
Practice Address - Fax:850-263-9726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAMPBELLTON-GRACEVILLE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-18
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003227500(RHC)Medicaid
FL003227501Medicaid
FL003227500Medicaid
FL003227501Medicaid