Provider Demographics
NPI:1316154834
Name:COLQUITT REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:COLQUITT REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-3420
Mailing Address - Street 1:2516 5TH AVE SE
Mailing Address - Street 2:PO BOX 3548
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-6207
Mailing Address - Country:US
Mailing Address - Phone:229-985-3420
Mailing Address - Fax:
Practice Address - Street 1:2516 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-6207
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLQUITT REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035069251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000694152AMedicaid
GA111542Medicare Oscar/Certification